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TEXT-BOOK 


OF 


HYGIENE 

A   Comprehensive    Treatise    on    the    Principles   and 

Practice  of  Preventive  Medicine  from  an 

American  Standpoint 


GEORGE    H.    ROHE,    M.D. 

Lath  Professor  of  Therapeutics,  Hygiene,  and  Mental  Diseases  in  the  College  of 
Physicians  and  Surgeons,  Baltimore,  Etc. 


ALBERT  ROBIN,  M.D. 

Professor  of  Pathology.  Bacteriology  and  Hygiene,  Medical  Department  Temple  University, 
and  Philadelphia  Dental  College;  Bacteriologist  City  Water  Department,  Wilmington, 
Delaware;    Member  American    Public   Health  Association,    Society  American 
Bacteriologists;    Corresponding  Member  International   Society  for 
THE  Prevention  of  Tuberculosis,  etc.  ;  Formerly  Patholo- 
gist AND  Bacteriologist  Delaware  State 
Board  of  Health. 


FOURTH    REVISED    AND    ENLARGED    EDITION 
With  Many  Illustrations  and  Valuable  Tables 


PHILADELPHIA 

F.  A.   DAVIS  COMPANY,    Publishers 

1908 


^A47.S 


•T^63 


\^^^ 


COPYRIGHT  1891, 

BY 

F.  A.  DAVIS 

COPYRIGHT,    1894, 

BV 

THE  F.  A.  DAVIS  COMPANY 
COPYRIGHT,  September,  1908, 

BY 

F.  A.  DAVIS  COMPANY 

[ Registered  at  Stationers'  Hall,  London,  England  J 


Philadelphia,  Pa.,  U.  S.  A. ; 

Press  of  F.  A.  Davis  Company 

1914-lC  Cherry  Street. 


PREFACE  TO  THE  FOURTH  EDITION. 


The  advances  made  in  hygiene  and  sanitary  science,  more  espe- 
cially in  the  field  of  causation  and  prevention  of  infectious  diseases, 
made  it  necessary  to  subject  this  well-known  and  popular  text-book  to 
a  thorough  revision.  Several  of  the  chapters  treating  of  subjects  in 
which  the  discoveries  were  more  recent  were  entirely  rewritten,  while 
others  were  brought  up-to-date  Ijy  including  such  matter  as  appeared 
essential  in  the  light  of  recent  advances. 

The  aim  of  the  editor  has  been  to  preserve  in  the  book  the 
qualities  which  made  it  one  of  the  most  popular  text-books  on  hygiene 
in  the  English  language. 

As  no  one  man  can  be  a  specialist  in  all  branches  of  hygiene  and 
sanitation,  it  was  necessary  to  secure  the  assistance  of  other  men. 
This  had  been  done  by  the  author  in  the  former  editions  of  this  book, 
and  the  plan  has  been  followed  by  the  editor  in  the  present  edition, 
with  this  exception,  however:  in  the  present  edition  credit  to  the 
several  eminent  contributors  is  given  here  in  the  preface. 

Dr.  Walter  Wyman,  Supervising  Surgeon-General,  TJ.  S.  Public 
Health  and  Marine-Hospital  Service,  has  revised  the  chapter  on 
"Quarantine."  The  chapters  on  "School  Hygiene,"  "Exercise  and 
Training,"  "Baths  and  Bathing,"  and  "Clothing,"  grouped  together 
with  one  chapter  heading  "Personal  Hygiene,"  were  prepared  by 
Dr.  Erancis  W.  Upshur,  lecturer  on  pathology,  hygiene,  public  health 
and  dietetics  in  the  University  College  of  Medicine,  Richmond,  Vir- 
ginia. The  chapter  on  "Military  and  Camp  Hygiene"  was  entirely 
rewritten  throughout  by  Walter  D.  McCaw,  Surgeon-Major,  Medical 
Department,  Surgeon-General's  Office,  Washington,  D.  C.  The  chap- 
ter on  "Naval  Hygiene"  also  was  entirely  rewritten  by  Henry  G. 
Beyer,  Major  Surgeon  United  States  Navy  and  professor  of  hygiene, 
etc.,  in  the  United  States  Army  and  Navy  Medical  School,  Washing- 
ton, D.  C. 

The  other  chapters  were  revised  and  supplemented  by  the  editor. 
It  is  hoped  that  this  edition  will  be  favored  with  the  same  cordial 
reception  accorded  to  former  editions  by  students  and  teachers 
throughout  the  country. 

A.    EOBIN. 
Wilmington,  Del. 


(ill) 


PREFACE  TO  THE  THIRD  EDITION. 


In  this  edition  every  chapter  has  been  subjected  to  a  careful 
revision,  and  the  advances  in  sanitary  science  and  practice  have  been 
incorporated. 

Eecent  legislation  in  the  United  States  and  Canada  has  almost 
revolutionized  quarantine  practice.  Surgeon-General  Walter  Wyman, 
and  Dr.  H.  D.  Geddings,  of  the  United  States  Marine-Hospital  Serv- 
ice, have,  at  the  request  of  the  author,  entirely  rewritten  the  chapter 
upon  "Quarantine,"  and  it  will  be  found  to  represent  fully  the  modern 
principles  and  practice  of  maritime  sanitation. 

Medical  Director  Albert  L.  Gihon,  United  States  Navy,  has  again 
thoroughly  revised  the  chapter  on  "Marine  Hygiene." 

With  the  view  of  making  the  book  still  more  useful  to  teachers, 
students,  and  sanitary  officers  than  heretofore,  an  analytical  set  of 
■^questions  has  been  appended  to  each  chapter,  and  a  separate  section 
has  been  added  on  methods  of  examination  of  air,  water,  and  food. 
For  these  additions  the  author  is  indebted  to  Professor  Seneca  Egbert, 
of  Philadelphia.  Dr.  Egbert  has  also  carefully  revised  the  chapter  on 
"Vital  Statistics." 

The  author  desires  to  thank  all  who  have  assisted  him  in  the 

work,  and  especially  the  sanitarians  throughout  the  country  who  have 

been  helpful  in  the  M^ay  of  criticism  and  suggestion.     He  hopes  that 

the  new  edition  will  merit,  as  well  as  receive,  the  approval  of  all 

students  of  preventive  medicine. 

G.  H.  E. 
Baltimore,  Md, 


(iv) 


PREFACE  TO  THE  FIRST  EDITION. 


The  aim  of  the  author  in  writing  this  book  has  been  to  place  in 
the  hands  of  the  American  student,  practitioner,  and  sanitary  officer, 
a  trustworthy  guide  to  the  principles  and  practice  of  preventive  medi- 
cine. 

He  has  endeavored  to  gather  within  its  covers  the  essential  facts 
upon  which  the  art  of  preserving  health  is  based,  and  to  present  these 
to  the  reader  in  clear  and  easily  understood  language. 

The  author  cannot  flatter  himself  that  much  in  the  volume  is 
new.    He  hopes  nothing  in  it  is  untrue. 

G.  H.  E. 


(V) 


CONTENTS. 


Chapter  Page 

I.— Air    '. 1 

II.— \Vater    46 

III.— Food    110 

IV.— Soil    160 

V. — Removal  of   Sewage 172 

VI. — Construction  of  Habitations 192 

VII. — Construction  of  Hospitals 219 

VIII.— School  Hygiene   ' 229 

IX. — Industrial  Hygiene   246 

X. — Military  and  Camjo  Hygiene 268 

XI. — Marine  Hygiene    285 

XII.— Prison  Hygiene 348 

XIII. — Personal  Hygiene    353 

XIV.— Disposal  of  the  Dead 369 

XV. — The  Germ  Theory  of  Disease 374 

XVI. — Contagion  and  Infection ' 385 

XVII. — History  of  Epidemic  Diseases 391 

XVIII. — Antiseptics,  Disinfectants  and  Deodorants 447 

XIX.— Vital   Statistics    462 

XX.— Quarantine   472 

Index    567 


(vii) 


LIST  OF  ILLUSTRATIONS. 


FIG.  ^^^^ 

1.  Organic  Matters  Frequently  Present  in  Dust   32 

2.  Air-tester   ^^ 

3.  Showing  Formation  of  Spring   55 

4.  Plans  of  30,000,000-Gallon  Storage  Reservoir   82 

5.  Plans   of   Intake   and   Water   Tower   Used   in    Connection   with   the 

Eeservoir •  ■  ■      ^^ 

6.  Plans  of  Slow  Sand  Filters    85 

7.  Showing  Interior  of  Filter  Recently  Constructed  in  Washington,  D.  C. .      89 

8.  Showing  Exact  Size  of  Filtering  Material  Used  in   Construction  of 

Sand  Filters 92 

9.  ShoAving  Interior  of  Mechanical  Filter  92 

10.  Chevallier's  Creamometer 124. 

11.  Pull-up  Handle  Commode    177 

12.  Showing  the  Apparatus  INIounted  on  Bearers  as  when  Fixed   177 

13.  Dry  Closet  178 

14.  Bury  Ventilator  in  Operation,  Inside  View 201 

15.  Bury  Ventilator  in  Operation,  Outside  View 201 

16.  Ventilation  of  a  Room  Containing  an  Open  Fireplace    202 

17.  The  "Dececo"  Closet   (New  Form)    207 

18.  The  "A.  G.  M."  Closet   208 

19.  Sectional  View  of  '-'A.  G.  M."  Closet 209 

20.  Flushing   Cistern  for  Water-closets    211 

21.  S-Trap    212 

22.  Sectional  View  of  Vent,  with  Cap  in  Xormal  Position   213 

23.  Sectional  View  of  Vent,  with  Cap  Lifted  Out  of  the  Mercury  by  the 

Inflowing  Current  of  Air   213 

24.  Connolly   Globe-trap    214 

25.  Globe-trap  Attached  to  Basin   214 

26.  Plan  of  Johns  Hopkins  Hospital 221 

27.  Bury  Ventilator  for  Use  in  School-rooms,  Inside  View 231 

28.  Bury  Ventilator  for  Use  in  School-rooms,  Outside  View   231 

29.  Adjustable  School-deck   (Front  View)    234 

30.  Myopia  According  to  School-classes — Boys    236 

31.  Myopia  According  to  School-classes — Girls   237 

32.  Showing  Influence  of  a  High  Desk  in  Causing  Spinal  Curvature   ....    239 

33.  Cross-section  of  Ship,  Showing  Arrangement  of  Drainage  System  .  .  .    299 

34.  Showing  Arrangement  of  Deck-planking   302 

35.  Showing  Location  of  Limber  Holes  303 

36.  Showing  Location  of  Bilge-space  in  Modern  Iron  Ship   304 

37.  Showing  Location  of  Bilge-space  on  Top  of  Double  Bottom 305 

38.  Showing  Plan  of  Large  Modern  Battleship 315 

39.  Distilling  Plant  as  Installed  in  Vessels  of  the  United  States  Navy  .  .    333 

40.  41,  42     Plans  Showing  Arrangement  of  Ventilation  on  the  Idaho  and 

Mississippi    342 

43.  Forms  of  Bacteria   ( From  Schenk)    375 

44.  Spirochaeta  Obermeieri,     X   380   419 

45.  Pure  Culture  of  Typhoid  Bacilli,  Showing  Clumping  when  Brought  in 

Contact  with  Blood  from  Typhoid  Patients,   (Widal  reaction)    .  .  .   421 

46.  Diphtheria  Bacilli   (Pari:)    427 

47.  IMicrococci  Gonorrhea  in  Pus   {Park )    433 

48.  Actinomyces  Hominis  {Lung) ,    X    350 435 

49.  Colony  of  Anthrax  Bacilli,  Slightly  Magnified,   (After  Flilgge)    436 

50.  Bacillus  Mallei    (Park) 437 

(viii) 


Text-Book  of  Hygiene. 


CHAPTER  I. 


AIR. 


Exact  investigation  into  the  influence  of  the  atmosphere  upon 
health  is  yet  in  its  infancy.  Enough  has  been  learned,  however,  to 
show  that  changes  in  the  composition  of  the  air,  in  its  density,  its  tem- 
perature, its  humidity,  its  rate  and  direction  of  motion,  and  possibly 
its  electrical  or  magnetic  conditions,  influence  in  various  ways  the 
health  of  the  individual.  It  is  only  very  recently  that  any  scientific 
attempts  have  been  made  to  trace  the  bearing  of  atmospheric  changes 
upon  health.  The  observations  already  recorded  indicate  that  a 
thorough  study  of  meteorological  phenomena  in  connection  with  the 
origin  and  progress  of  certain  diseases  is  a  promising  field  of  labor 
for  the  educated  sanitarian.  The  meteorological  observations  which 
have  been  gathered  by  the  United  States  Signal  Service,  together 
with  elaborate  studies  made  by  the  meteorologists  and  climatologists 
of  other  countries,  already  form  such  a  large  and  tolerably  complete 
and  well-arranged  body  of  facts,  that  reasonably  accurate  deductions 
can  even  now  be  made.  Heretofore,  in  studying  the  sanitary  relations 
of  the  atmosphere,  both  in  this  country  and  abroad,  the  attention 
of  observers  has  been  riveted  almost  exclusively  upon  the  changes 
in  its  composition  occurring  within  certain  limited  areas.  It  is, 
perhaps,  equally  important  to  study  this  universally  diffused  and 
necessary  condition  of  vital  activity  in  its  broader  and  more  general 
relations.  It  will  be  shown,  in  the  course  of  the  present  work,  that 
the  meteorological  features  of  countries,  or  of  seasons,  or  even  the 
daily  atmospheric  changes,  exercise  an  important  influence  upon  life 
and  health.  In  order  to  fully  appreciate  these  relations  it  will  be 
necessary  to  first  give  a  brief  summary  of  the  facts  and  laws  of 
meteorology. 

(1) 


2  TEXT-BOOK  OF  HYGIENE. 

THE    COMPOSITION    AND    PHYSICAL    CONDITIONS    OF    THE 
ATMOSPHERE. 

Atmospheric  air  has  the  following  composition : — 

Oxygen   20.91  per  cent. 

Nitrogen 77.95 

Argon    1.00         " 

Carbonic  acid    0.04        " 

Aqueous  vapor  variable. 

Traces  of  organic  matter,  ozone,  mineral  salts,  ammonia,  niti-ic  acid, 
krypton,  neon,  metargon,  carburetted  hydrogen. 

These  proportions  are  maintained,  with  but  very  little  change, 
at  different  heights.  At  first  thought,  it  would  seem  that  carbon 
dioxide,  being  much  heavier  than  the  other  constituents  of  air,  would 
accumulate  in  the  lower  regions  of  the  atmosjohere,  and  there  cause 
an  excess  of  this  poisonous  constituent ;  but  in  obedience  to  the  law  of 
diffusion  the  intermingling  of  the  component  gases  is  perfect,  and 
the  proportion  of  carbon  dioxide  in  the  atmosphere  is  quite  as  great  on 
mountain-tops  as  in  the  deepest  valleys.  This  diffusion  of  gases, 
however,  is  modified  by  the  wind  and,  in  cities,  by  high  buildings. 

The  proportion  of  nitrogen  in  atmospheric  air  is  generally  uni- 
form, while  that  of  oxygen  varies,  depending  to  a  great  extent  upon 
the  amount  of  carbon  dioxide  present.  Hence,  an  increase  in  the 
amount  of  the  latter  constituent  is  usually  accompanied  by  a  diminu- 
tion of  oxygen,  inasmuch  as  the  formation  of  carbon  dioxide  can  only 
take  place  at  the  expense  of  oxygen.  The  reciprocal  activities  of  ani- 
mal and  vegetable  life  are  beautifully  illustrated  by  these  relations 
between  the  oxygen  and  carbon  dioxide  in  the  air.  In  the  processes 
of  combustion  and  oxidation,  oxygen  is  withdrawn  from  the  atmos- 
phere, and  combines  with  carbon,  forming  carbon  dioxide.  During 
vegetable  growth,  on  the  other  hand,  carbon  dioxide  is  withdrawn 
from  the  air  by  the  leaves  of  plants,  and  decomposed  into  its  ele- 
ments, carbon  and  oxygen.  The  carbon  is  used  in  building  up  the 
plant,  while  the  liberated  oxygen  is  restored  to  the  atmosphere.  The 
animal  consumes  oxygen,  an'd  gives  out  carbon  dioxide;  the  plant 
resolves  this  compound  into  its  constituent  elements,  and  gives  back 
the  oxygen  to  the  air.  However,  at  night,  or  in  the  absence  of  sun- 
light, plants  evolve  carbon  dioxide  instead  of  oxygen,  and  for  this 
reason  it  is  injurious  to  keep  plants  in  bedrooms  over  night. 

The  atmosphere  extends  upward  from  the  surface  of  the  earth 
to  an  indefinite  distance.  The  limit  has  been  variously  placed  at 
from  75  kilometres  to  40,000  kilometres.     For  all  sanitary  purposes 


COMPOSITION  AND  CONDITIONS  OF  ATMOSPHERE.  3 

the  former  may  be  taken  as  the  upward  limit  of  the  atmosphere.  In 
obedience  to  the  law  of  gravity,  this  mass  of  air  presses  everywhere 
directly  downward — toward  the  earth's  centre — with  a  force  equal 
to  its  weight.  If  a  column  of  this  air  be  balanced  by  a  column  or 
mass  of  any  other  matter — the  columns  being  of  the  same  diameter — 
we  have  a  relative  measure  of  the  weight  of  the  atmosphere.  The 
instrument  with  which  the  weiglit  or  downward  pressure  of  the  air 
is  measured  is  called  a  barometer.  The  atmosphere,  at  the  sea-level, 
presses  downward  with  a  force  equal  to  the  pressure  of  a  column  of 
mercury  760  millimetres  high.  Hence,  the  barometric  pressure  at 
sea-level  is  said  to  be  760  millimetres,  or  30  inches.  If  the  barometer 
be  carried  to  the  summit  of  a  mountain  1000  metres  above  the  level 
of  the  sea,  or  be  taken  to  the  same  altitude  in  a  balloon,  the  mercury 
in  the  barometer-tube  will  fall  about  90  millimetres.  These  90 
millimetres  of  the  mercurial  column  represent  the  weight  of  1000 
metres  of  air  now  below  the  barometer,  and  consequently  not  meas- 
ured or  balanced  by  it.^ 

Upon  ascending  from  the  sea-level,  it  is  found  also  that  the 
air,  being  less  pressed  upon  by  that  which  is  still  above  it,  becomes 
more  rarefied  and  lighter ;  its  tension,  as  it  is  termed,  is  less.  Hence, 
for  the  second  1000  metres  of  ascent  above  the  sea,  the  mercury  will 
fall  a  less  distance  in  the  tube,  the  weight  removed  not  being  so  great 
as  in  the  first  1000  metres. 

The  following  table  shows  the  diminution  in  atmospheric  pres- 
sure for  every  1000  metres  above  sea-level: — 

Table  I. 

Sea-level    760.0  millimetres. 

1,000  metres 670.4  " 


2,000 

3,000 

4,000 

5,000 

6,000 

7,000 

8,000 

9,000 

10,000 

11,000 

12,000 

15,000 

20,000 


591.5 
521.0 
460.3 
406.0 
358.2 
316.0 
278.8 
245.9 
216.9 
191.1 
168.8 
115.9 
61.9 


^Tho  fij^ires  here  given  are  not  absolute,  but  merely  approximate.  The 
limits  of  tbis  work  do  not  allow  a  full  discussion  of  the  meteorological  ele- 
ments modifying  the  pressure  of  the  atmosphere  at  sea-level. 


4  TEXT-BOOK  OF  HYGIENE. 

Variations  in  temperature  gnd  humidity  of  the  air  influence  the 
tension  of  the  atmosj)here  in  a  marked  degree,  and  affect  tlie  height 
of  the  barometric  column.  In  fact,  most  of  the  changes  of  atmos- 
pheric jjressure  at  the  surface  of  tlie  earth  are  directly  due  to  changes 
in  temjDcrature  and  humidity.  Increase  of  temperature  diminishes 
the  density  of  the  air.  Hence,  when  the  temperature  rises  the  pres- 
sure decreases. 

The  proportion  of  moisture  (aqueous  vapor),  if  increased,  like- 
wise caiises  a  diminution  in  pressure.  It  is  found,  for  example,  that 
when  the  amount  of  aqueous  vapor  in  the  air  increases,  the  barometer 
falls.  This  is  due  to  the  fact  that  the  specific  gravity  of  aqueous  vapor 
is  less  than  that  of  dry  air,  being  in  the  i^roportion  of  .623  to  1.000, 
Hence,  as  aqueous  vapor  is  diffused  through  the  air,  the  latter  becomes 
lighter, — or,  in  other  words,  the  barometric  pressure  diminishes. 

The  warmth  of  the  air  is  primarily  derived  from  the  sun.  On 
a  clear  day  about  one-fourth  of  the  heat  of  the  sun's  rays  is  given 
off  directly  to  the  air  during  the  passage  of  the  heat-rays  to  the  earth. 
Of  the  remaining  three-fourths,  part  is  reflected  from  the  earth, 
while  the  larger  portion  is  first  absorbed  by  the  earth  and  then  given 
off  by  radiation  and  convection  to  the  superincumbent  air. 

The  air  is  always  warmer  near  the  earth's  surface  on  a  clear, 
sun-shiny  day;  for,  as  soon  as  the  earth  gets  warmer  than  the  air 
immediately  above  it,  the  excess  of  heat  is  given  off  to  the  latter  by 
convection  and  radiation.  On  ascending  from  the  surface  of  the 
earth  the  temperature  decreases,  and  on  the  summit  of  a  high  moun- 
tain the  air  is  always  colder  than  at  its  base.  The  decrease  of  tem- 
perature with  the  ascent  equals  1°  P.  to  every  300  feet. 

Professor  Tyndall  has  shown  that  dry  air  absorbs  less  heat  thnn 
air  which  is  charged  with  vapor.  Por  this  reason  the  sun's  rays  strike 
the  earth  with  much  greater  intensity  on  a  very  dry  than  on  a  moist 
day,  while  on  the  latter  a  larger  proportion  of  the  heat-rays  is  inter- 
cepted before  they  reach  the  earth. 

Eecent  experiments  seem  to  show,  however,  that  the  difference 
in  diathermancy  between  dry  and  humid  air  is  not  so  great  as  sup- 
posed by  Tyndall.  The  depth  of  the  air-stratum,  through  which  the 
sun's  rays  pass,  is  of  greater  influence  than  the  humidity. 

Air,  at  different  temperatures,  is  capable  of  absorbing  different 
amounts  of  aqueous  vapor.  Thus,  air  at  a  temperature  of  4°  will 
require  a  much  smaller  amount  of  vapor  to  produce  saturation  than 
air  at  a  temperature  of  30°.  Por  this  reason  air  which  appears 
^^damp"  at  the  former  temperature,  both  to  the  bodily  sensations  and 


COMPOSITION  AND  CONDITIONS  OF  ATMOSPHERE.  5 

to  appropriate  instruments,  would  be  considered  as  ''dry"  at  the  latter 
temperature,  although  the  actual  amount  of  vapor  present,  or  absolute 
humidity,  is  the  same  in  both  cases."  In  meteorological  observations 
for  sanitary  purposes,  the  relative  humidity  is  the  condition  deserving 
especially  careful  study. 

It  must  be  borne  in  mind  that  the  mere  statement  of  the  per- 
centage of  relative  humidity,  without  taking  into  account  the  tem- 
perature of  the  air,  is  of  little  significance.  A  ]ike  remark  is  justi- 
fied with  regard  to  statements  of  absolute  humidity,  when  used  to 
illustrate  the  apparent  effects  of  atmospheric  moisture  upon  life  and 
health. 

The  following  table  shows  the  absolute  humidity  correspond- 
ing to  the  same  relative  humidity  at  different  temperatures.  It  also 
includes  the  total  possible  absolute  humidity  and  the  difference  be- 
tween the  actual  and  possible  humidity  (deficiency  of  saturation)  at 
the  temperatures  given: — 

Table  II. 


Tempera- 
ture °C. 

Relative 
Humidity 
(percent). 

Absolute  Humidity 
(grammes  per 
cubic  metre). 

Greatest  Possible 
Absolute  Humidity. 

Deficiency  of 
Saturation. 

—20 

—10 

0 

-flO 

20 

30 

60 
60 
60 
60 
60 
60 

0.638 
1.380 
2.924 
5.623 
10.298 
18.083 

1.064 
2.300 
4.874 
9.372 
17.164 
30.139 

0.426 
0.920 
1.950 
3.749 
6.866 
12.056 

In  forests  the  relative  humidity  is  usually  higher  than  over  un- 
wooded  districts,  although  the  absolute  humidity  may  be  the  same, 
or,  perhaps,  even  less.  The  evaporation  is  usually  much  greater  in 
the  open  air  than  in  forests.  In  closed  apartments  the  evaporation 
may  be  greater  or  less  than  in  the  open  air,  depending  upon  the 
local  conditions  present. 


^By  "absolute  humidity"  is  meant  the  total  amount  of  vapor  present 
in  a  certain  mass  of  air.  By  the  term  "relative  humidity"  meteorologists 
designate  the  proportion  of  vapor  present  at  certain  temperatures,  compared 
with  full  saturation  of  the  air  Avith  vapor,  which  is  reckoned  100.  Thus,  air 
which  is  satu7-ated,  or  whose  relative  humidity  is  100  at  4°,  would  have  a 
relative  humidity  of  only  24,  if  the  temperature  were  raised  to  27°,  because 
in  the  latter  case  the  capacity  of  the  air  for  aqueous  vapor  is  increased. 
Relative  humidity  is  always  desif^Tiated  in  percentages;  absolute  humidity  in 
grammes  per  cubic  metre  or  grains  per  cubic  foot. 


6  TEXT-BOOK  OF  HYGIENE. 

The  motion  of  the  air — wind — is  caused  by  differences  in 
presssure;  tlae  latter  being  due  to  differences  in  temperature  and 
humidity.  A  mass  of  air  traversing  a  large  body  of  water  absorbs 
vapor,  unless  already  saturated,  and  becomes  moist;  if  it  pass  over 
a  wide  tract  of  dry  land  it  loses  moisture  and  becomes  dry.  There- 
fore in  the  eastern  portion  of  the  American  continent,  an  easterly 
or  southerly  wind,  which  comes  from  over  large  bodies  of  water,  and 
which  is  usually  warm,  and  thus  capable  of  holding  a  large  quantity 
of  water  in  a  state  of  vapor,  is  always  moist.  On  the  other  hand,  a 
northerly  or  westerly  wind,  coming  over  a  large  extent  of  dry  land, 
and  from  a  colder  region,  is  nearly  always  a  dry  wind.  On  the 
Pacific  coast  these  conditions  are  reversed;  there  a  westerly  wind  is 
a  moist  wind,  while  an  easterly  wind  is  dry.  The  dreaded  easterly 
wind  of  England  is  likewise  a  dry  wind.  It  is  probable  that  the 
direction  and  rate  of  motion  of  air-currents  have  consideral^le  in- 
fluence upon  the  origin  or  intensification  of  certain  diseases. 

The  electrical  and  magnetic  conditions  of  the  atmosphere  have 
been  as  yet  studied  to  little  advantage.  It  is  only  known  that  atmos- 
pheric electricity  is,  in  most  cases,  positive,  and  that  its  intensity  in- 
creases with  condensation  of  vapor.  There  seems  to  be  no  doubt  that 
the  varying  states  of  atmospheric  electricity  are  closely  connected  with 
evaporation  and  condensation.  There  is  reason  to  believe  that  a 
fuller  knowledge  on  these  toj)ics  will  yield  most  important  results 
to  the  student  of  hygiene. 

Ozone,  which  is  oxygen  in  an  allotropic  and  highly  active  con- 
dition (O3),  is  generally  absent  from  town  air;  and  when  it  does 
appear,  as  after  a  summer  storm,  it  is  in  such  insignificant  amount 
as  to  have  no  influence  on  health. 


BACTERIA    IN   THE   AIR. 

In  localities  which  are  free  from  human  or  animal  habitation, 
as  in  open  plains,  high  moutains,  midocean,  etc.,  the  air  is  free  from 
bacteria;  on  the  other  hand,  bacteria  will  be  present  wherever  man 
or  animal  abides.  The  number  of  bacteria  will  be  in  direct  proportion 
to  the  density  of  the  population,  the  larger  number  being  found  in 
cities,  and,  again,  in  the  overcrowded  portions  of  the  large  centres 
of  population.  Defective  sanitation  will  increase  the  number  of  bac- 
teria. In  addition  to  bacteria,  the  air  contains  yeasts  and  the  spores 
of  moulds  and  of  the  lower  fungi.  The  moulds  are  provided  Avitli 
fine  spore-bearing  filaments,  which  become  detached  and  float  in  a 


INFLUENCE  OF  ATMOSPHERIC  PRESSURE.  7 

free  condition.  The  bacteria,  on  the  other  hand,  do  not  float,  but  are 
carried  by  particles  of  dust  or  moisture.  The  epoch-making  experi- 
ments of  Pasteur  and  Tyndall  have  demonstrated  the  axiomatic 
proposition  that  without  dust  there  are  no  bacteria.  Consequently, 
any  disturbance  which  raises  dust  wiil  also  increase  the  number  of 
bacteria  in  the  air,  and,  conversely,  any  agent  which  allays  dust  also 
purifies  the  air.  It  is  for  this  reason  that  the  use  of  a  damp  cloth 
is  preferable  to  dusting,  and  a  carpet-sweeper  is  more  sanitary  than  a 
broom.  The  bacteria  present  in  the  air  may  be  of  three  kinds: 
(1)  Harmless  bacteria;  (2)  bacteria  which  produce  putrefaction; 
and  (3)  bacteria  which  cause  disease.  The  latter  are  the  most  im- 
portant and  are  derived  from  sick  persons.  The  actions  of  cough- 
ing, sneezing,  speaking,  and  even  of  deep  breathing  distribute  min- 
ute droplets  of  secretions  from  the  respiratory  passages  and  thus 
infect  the  atmosphere.  Diphtheria,  influenza,  pneumonia,  whooping 
cough,  tuberculosis,  and  other  infections  of  the  respiratory  organs 
may  be  and  are  communicated  in  this  way.  The  fine  particles  of  the 
bacteria-laden  secretions  may  be  directly  inhaled  by  the  person 
standing  in  front  of  the  mouth  of  the  patient,  or  else  they  fall  to 
the  ground,  dry  out,  and  dry  bacteria  are  carried  by  the  dust  into 
the  air.  It  is  in  this  way  that  the  sputum  from  consumptives  be- 
comes a  serious  and  constant  source  of  infection.  In  eruptive  fevers, 
like  measles,  scarlet  fever,  small-pox,  etc.,  the  causative  agent,  still 
unknown,  is  eliminated  through  the  skin  and  carried  into  the  air 
by  the  fine  particles  of  dry  epithelium.  The  bacilli  of  typhoid  fever 
and  cholera  may  also  find  their  way  into  the  air  through  the  drying 
of  infected  sewage  or  water,  or  the  excreta  from  the  patient  may  be- 
come mixed  with  dust,  and,  when  dry,  be  carried  into  the  air  and 
subsequently  deposited  in  water,  milk,  or  other  food.  That  infection 
by  this  method  is  not  more  frequent  is  due  to  the  fact  that  many 
pathogenic  bacteria  are  destroyed  by  drying  and  sun-light. 

INFLUENCE   OF   CHANGES   OF   ATMOSPHERIC   PRESSURE 
ON    HEALTH. 

The  effects  of  a  considerable  diminution  of  pressure  are  familiar 
to  every  one  in  the  "mountain  sickness"  which  attacks  most  persons 
on  ascending  high  mountains.  M.  Bert  has  shown  experimentally 
that  similar  effects  can  be  produced  in  an  air-tight  chamber  by 
diminishing  the  pressure.  The  symptoms  produced  under  a  pres- 
sure equivalent  to  an  altitude  of  from  4000  metres  to  5000  metres 


8  TEXT-BOOK  OF  HYGIENE, 

were  a  feeling  of  heaviness,  nausea,  ocular  fatigue,  rapidity  of  pulse, 
convulsive  trembling  on  slight  exertion,  and  a  sensation  of  languor 
and  general  indifference  to  the  surroundings  of  the  individual. 

M.  Lortet,  who  has  left  on  record  his  experiences  in  the  higher 
Alps,  says  that  the  symptoms  noticed  on  ascending  to  high  altitudes 
are:  Labored  respiration,  increased  rapidity  of  pulse,  depression  of 
temperature  (as  much  as  4°  to  7°  C).  The  normal  temperature 
was  restored,  however,  after  a  brief  rest.  Still  more  severe  symp- 
toms have  been  noticed  on  ascending  high  mountains  in  South 
America  and  Asia.  Aeronauts  have  lost  consciousness,  and  in  several 
instances  life,  on  rapidly  ascending  to  great  altitudes.^  According  to 
the  observations  of  the  brothers  Schlagintweit,  distinguished  ex- 
plorers of  the  highlands  of  Asia,  the  effects  of  diminished  pressure 
upon  the  human  organism  are:  "Headache,  difficulty  of  respiration, 
and  affections  of  the  lungs, — the  latter  even  proceeding  so  far  as  to 
occasion  blood-spitting, — want  of  appetite,  and  even  nausea,  muscular 
weakness,  and  a  general  depression  and  lowness  of  spirits.  All  these 
sj^mptoms,  however,  disappear  in  a  healthy  man  almost  simul- 
taneously with  his  return  to  lower  regions."  A  singular  observation 
was  made  by  these  travelers  on  the  effect  of  motion  of  the  air  upon 
the  s}Tnptoms  described.  They  say:  "The  effects  here  mentioned 
were  not  sensibly  increased  by  cold,  but  the  wind  had  a  most  decided 
influence  for  the  worse  upon  the  feelings.  .  .  .  When  occupied 
with  observations,  we  took  very  little,  if  any,  bodily  exercise,  some- 
times for  thirty-six  hours;  it  would  frequently  occur  nevertheless, 
even  in  heights  not  reaching  17,000  feet  (about  5150  metres),  that 
an  afternoon  or  evening  wind  would  make  us  all  so  sick  as  to  take 
away  every  inclination  for  food.  No  dinner  was  cooked;  the  next 
morning,  when  the  wind  had  subsided,  the  appetite  was  better. 

"The  effects  of  diminished  pressure  are  considerably  aggravated 
by  fatigue.  It  is  surprising  to  what  degree  it  is  possible  for  ex- 
haustion to  supervene;  even  the  act  of  speaking  is  felt  to  be  a  labor, 
and  one  gets  as  careless  of  comfort  as  of  danger.  Many  a  time  our 
people— those  who  ought  to  have  served  us  as  guides — ^would  throw 
themselves  down  upon  the  snow,  declaring  they  would  rather  die 
upon  the  spot  than  proceed  a  step  farther."* 


»MM.  Sivel  and  Croce-Spinelli,  two  aeronauts,  lost  their  lives  in  this 
manner  during  an  ascent  from  Paris,  in  April,  1875. 

*  Results  of  a  Scientific  Mission  to  India  and  High  Asia.  By  Hermann, 
Adolphe,  and  Robert  De  Schlagintweit,  vol.  ii,  pp.  484,  485, 


INFLUENCE  OF  ATMOSPHERIC  PRESSURE.  9 

These  symptoms  disappear  when  persons  are  exposed  to  these 
conditions  for  a  prolonged  time.  Thus,  in  the  Andes  there  are  places 
4000  metres  above  sea-level  which  are  permanently  inhabited;  and 
in  the  Himalayas  there  are  villages  at  a  height  of  over  5000  metres 
constantly  occupied.  In  this  country,  Pike's  Peak,  4350  metres 
above  the  sea,  has  been  occupied  since  1873  by  observers  of  the  signal 
service.  The  men  seem  to  become  acclimated,  as  it  were,  and  suffer 
little  or  no  inconvenience  from  the  diminished  pressure  after  a  time. 

The  minor  disturbances  of  healthy  function  produced  by  dimin- 
ished pressure  (within  the  limits  of  4000  metres  altitude,  or  460  milli- 
metres barometric  pressure)  are  an  increase  in  the  pulse  and  respira- 
tion rate.  This  is  probably  due  to  the  struggle  of  the  organism  to 
take  up  the  required  quantity  of  oxygen,  which  is  reduced  in  propor- 
tion by  the  rarefaction  of  the  air.  For  example,  the  proportion  of 
oxygen  at  a  pressure  of  460  millimetres  would  be  equivalent  to  12.6 
per  cent,  at  sea-level,  instead  of  the  normal  20.9  per  cent. 

Paul  Bert  has  shown  by  personal  experiments  in  the  pneumatic 
chamber  that  the  increase  in  pulse  and  respiration  rate  is  not  due  to 
the  merely  mechanical  diminution  of  pressure,  but  to  the  deficiency 
of  oxygen.  Hence  the  physiological  effects  of  high  altitudes  upon 
circulation  and  respiration  are  not  purely  physical,  due  to  dimin- 
ished pressure,  but  vital,  and  depend  upon  the  change  in  the  chemical 
composition  of  the  atmosphere.  The  simple  diminution  of  oxygen 
without  reduction  of  pressure  will  produce  similar  though  not  identi- 
cal effects  upon  the  organism. 

Above  the  height  of  4000  metres  above  sea-level  (below  460 
millimetres  pressure)  the  profounder  disturbances  of  function  char- 
acterized as  "mountain  sickness"  come  on.  Different  individuals  re- 
act in  different  degree  to  the  morbific  influences  of  greatly  dimin- 
ished atmospheric  pressure  (and  coincident  reduction  of  oxygen). 
Thus  Glaisher  reached  an  elevation  of  11,000  metres  (191.1  milli- 
metres pressure)  and  returned  to  the  earth  alive,  while  Croce- 
Spinelli  and  Sivel  perished  at  the  considerably  lower  elevation  of 
8000  metres,  equivalent  to  a  pressure  of  260  millimetres  (7.2  per 
cent,  of  oxygen). 

The  sanitarian  is  most  concerned  about  the  effects  of  pressure  of 
the  atmosphere  from  760  millimetres  down  to  460  millimetres  (or  up 
to  an  altitude  of  4000  metres  above  sea-level).  The  climatotherapy 
of  various  diseases  requires  that  the  effects  of  variations  of  pressure 
between  these  limits  should  be  carefully  studied.     The  observations 


10  TEXT-BOOK  OF  HYGIENE. 

of  Mermod  and  Jourdanet^  have  illustrated  the  common  physiological 
effects  of  these  circumscribed  changes,  while  the  experiences  of 
therapeutists  have  established  the  fact  very  clearly  that  many  cases 
of  phthisis  improve  markedly  in  a  rarefied  atmosphere,  provided,  how- 
ever, they  are  not  subject  to  hemorrhages,  in  which  case  high  altitude 
increases  the  liability  to  hemoptysis.  Other  obs3rvers  have  also 
shown  that  the  effects  of  diminished  pressure  are  not  always  bene- 
ficial, and  Dr.  Loomis  has  warned  against  the  sending  of  patients 
with  heart  disease  to  high  altitudes.  Whether  the  lethal  effects  that 
have  been  recorded  in  such  cases  are  due  to  the  increased  activity  of 
the  heart  and  heightened  blood-pressure  from  deficient  oxygen,  or  as 
suggested  by  Dr.  F.  Donaldson,  Jr.,  to  dilatation  of  the  heart-walls 
from  diminution  of  external  pressure,  is  as  yet  unsettled." 

It  is  probable  that  the  diurnal  or  accidentaP  oscillations  of 
barometric  pressure  at  sea-level  have  no  appreciable  influence  upon 
the  organism.  The  statement  is  occasionally  met  that  patients  sub- 
jected to  grave  surgical  operations  often  do  badly  during  low  at- 
mospheric pressure,  and  some  surgeons  never  operate  when  the 
barometer  is  low  or  falling  if  they  can  avoid  it.  An  inquiry  under- 
taken by  the  writer  in  1876,  in  which  the  excellent  records  of  the 
Massachusetts  General  Hospital  and  the  observations  of  the  Boston 
station  of  the  United  States  Signal  Service  for  five  years  were  used 
as  the  basis  of  comparison,  resulted  negatively.  The  deaths  follow- 
ing operations  done  on  days  when  the  barometer  was  high  or  rising 
were  exactly  equal  in  number  to  those  following  operations  when  the 
barometer  was  low  or  falling.  Unfortunately,  the  investigation  was 
never  pursued  to  the  extent  of  including  other  meteorological  ele- 
ments, such  as  humidity,  cloudiness,  precipitation,  etc.  The  numer- 
ous studies  of  the  relations  of  variations  of  pressure  to  the  progress 
of  infectious  diseases  have  also  failed  to  yield  any  fruits  of  value. 
Whether  the  nerve-pains  so  frequently  complained  of,  especially  by 
elderly  patients,  during  the  progress  of  areas  of  low  barometer,  are 
due  to  the  diminished  pressure,  or  to  the  influence  of  some  other 
meteorological  factor,  such  as  humidity  or  electrical  condition,  can- 
not yet  be  decided. 


^  Jourdanet  states  that  while  the  French  and  Belgian  soldiers  in  IMexico 
had  an  accelerated  pulse,  the  natives  had  a  nonnal  pulse.  In  Mermod's  ob- 
servations the  average  frequency  of  the  pulse  at  St.  Croix  (1106  metres  above 
sea-level)  was  nearly  four  beats  greater  than  at  Strassburgh  (142  metres). 
The  condition  of  the  natives  at  the  high  settlements  of  the  Andes  and  Hima- 
layas has  not  yet  been  investigated  with  exactitude. 

*  American  Climatological  Association,  1887. 

''  Meaning  the  oscillation  produced  by  storm  waves. 


INFLUENCE  OF  TEMPERATURE  ON  HEALTH.  H 

Increased  atmospheric  pressure,  as  noticed  in  caissons,  tunnels, 
and  mines,  produces  increase  in  frequency  and  depth  of  respiration, 
diminution  in  the  number  of  beats  and  volume  of  the  pulse,  pallor 
of  the  skin,  increase  of  perspiration  (although  Smith  states  that 
this  is  only  apparent  and  due  to  lack  of  evaporation  from  the  sur- 
face), increased  appetite,  and  more  abundant  excretion  from  the 
kidneys. 

Among  the  distinctly  pathological  effects  of  increased  atmos- 
pheric pressure  are  rupture  of  the  drum  of  the  ear,  pain  in  the  frontal 
and  maxillary  sinuses,  neuralgic  pains,  nausea,  sometimes  vomiting, 
and  local  paralyses.  Dr.  A.  H.  Smith^  defines  this  collection  of 
symptoms  as  "The  Caisson  Disease,"  and  gives  the  following  sum- 
mary of  its  characteristic  features : — 

"A  disease  depending  upon  increased  atmospheric  pressure,  but 
alvi^ays  developed  after  the  pressure  is  removed.  It  is  character- 
ized by  extreme  pain  in  one  or  more  of  the  extremities,  and  some- 
times in  the  trunk,  and  which  may  or  may  not  be  associated  with 
epigastric  pain  and  vomiting.  In  some  cases  the  pain  is  accompanied 
by  paralysis  more  or  less  complete,  which  may  be  general  or  local, 
but  is  most  frequently  confined  to  the  lower  half  of  the  body.  Cere- 
bral symptoms,  such  as  headache  and  vertigo,  are  sometimes  present. 
The  above  symptoms  are  connected,  at  least  in  the  fatal  cases,  with 
congestion  of  the  brain  and  spinal  cord,  often  resulting  in  serous 
or  sanguineous  effusion,  and  with  congestion  of  most  of  the  abdominal 
viscera." 

The  measures  to  be  adopted  in  preventing  "Caisson  Disease" 
are:  (1)  Working  during  short  shifts,  from  2  to  4  hours;  (2) 
abundant  supply  of  fresh  air;  (3)  the  use  of  electric  light,  so  as  to 
save  the  oxygen;  (4)  slow  decompression,  at  the  rate  of  one  minute 
for  every  three  pounds  of  pressure.  The  disregard  of  the  last  rule 
has  recently  caused  several  deaths  among  laborers  working  in  the 
tunnels  under  the  Hudson  Eiver. 


INFLUENCE  OF  CHANGES  OF  TEMPERATURE  ON  HEALTH. 

Many  of  the  derangements  of  health  ascribed  to  high  temj)era- 
ture  are  to  a  considerable  degree  due  to  other  factors,  prominent 
among  which  are  high  humidity,  intemperance,  overwork,  and  over- 
crowding.    There  can  be  little  doubt,  however,  that  the  importance 


*The    Physioloffical,    Pathological,    and    Therapeutical    Effects    of    Com- 
pressed Air,  p. '47,  Detroit,  1886. 


12  TEXT-BOOK  OF  HYGIENE. 

of  the.  high  temperature  itself  can  hardly  be  overrated.  It  has  been 
generally  accepted  heretofore  that  a  high  temperature,  together  with 
a  high  relative  humidity,  is  most  likely  to  be  followed  by  sun-stroke. 
A  careful  comparison  in  a  series  of  deaths  from  sun-stroke  in  the 
city  of  Cincinnati  in  the  summer  of  1881  shows,  however,  conclu- 
sively that  a  very  high  mean  temperature  with  a  low  relative  humidity 
is  more  liable  to  be  followed  by  sun-stroke  than  the  high  tempera- 
ture when  accompanied  by  a  high  humidity.  The  same  series  of  ob- 
servations also  shows  that  the  number  of  deaths  was  greater  on  clear 
days  than  on  cloudy  or  partly  cloudy  days.°  A  corroboration  of  this 
result  is,  found  in  the  fact  that  sun-strokes  very  rarely  occur  on  ship- 
board, at  sea,  where  the  relative  humidity  is  always  high. 

The  direct  influence  of  the  sun's  rays  upon  the  skin  produces  at 
times  an  erythematous  affection  which  may  run  into  a  dermatitis  if 
the  insolation  is  prolonged.  Artificial  heat  may  produce  similar 
effects. 

The  prevention  of  sun-stroke  should  include  the  wearing  of  light 
and  loosely-girded  clothing,  so  as  to  favor  the  rapid  evaporation  of 
perspiration ;  the  use  of  cool,  but  not  ice-cold  water ;  total  abstinence 
from  alcoholic  beverages;  and  the  maintenance  of  the  functions  of 
the  alimentary  canal  in  a  healthy  condition.  Constipation  should  be 
particularly  guarded  against.  Severe  muscular  exertion  should  be 
avoided  during  the  hottest  part  of  the  day. 

Diarrheal  diseases,  both  of  adults  and  children,  are  much  more 
frequent  during  hot  than  cold  weather  (and  in  hot  than  in  cold 
climates),  but  it  is  probable  that  other  factors,  as  the  more  ready 
putrefaction  of  food,  aid  in  the  production  of  these  diseases  besides 
the  high  temperature. 

Certain  epidemic  diseases  are  likewise  more  frequent  in,  or  ex- 
clusively confined  to,  hot  climates.  These  are  cholera,  yellow  fever, 
and  epidemic  dysentery.  Elephantiasis,  malarial  fevers,  and  certain 
skin  diseases  seem  also  to  have  some  connection  with  a  constantly 
high  external  temperature.  The  intimate  relation  between  cause  and 
effect  is  not  clearly  understood,  although  the  belief  is  current  that 
the  origin  and  spread  of  such  diseases  depend  upon  the  development 
of  various  parasitic  organisms. 

Eegarding  the  morbific  effects  of  continued  high  temperatures, 
it  is  probable  that  an  appropriate  mode  of  life,  proper  diet,  and  suit- 
able clothing  would  avert  many  of  the  bad  consequences.     Neverthe- 


"The  Sun-stroke  Epidemic  of  Cincinnati,  0.,  during  the  Summer  of  1881. 
A.  J.  Miles,  Public  Health,  vol.  vii,  pp.  293-304. 


INFLUENCE  OF  TEMPERATURE  ON  HEALTH.  13 

less,  the  fact  remains  that  certain  tropical  or  hot-weather  diseases 
must  be  considered  as  primarily  dependent  upon  high  temperature, 
although  the  pathological  effects  may  be  due  to  an  intermediate  fac- 
tor. It  is  not  improbable  that  micro-organisms  will  be  found  to  ex- 
plain the  occurrence  of  yellow  fever,  cholera  infantum,  and  other  dis- 
eases incident  to  hot  weather. 

Extreme  low  temperature,  as  observed  in  the  arctic  regions, 
seems  to  produce  a  progressive  deterioration  of  the  blood  (anemia), 
in  consequence  of  which  most  natives  of  temperate  regions  v/ho  are 
compelled  to  remain  in  the  far  north  longer  than  two  winters  suc- 
cumb to  various  hemic  diseases,  scurvy  being  the  most  prominent. 
It  is  not  improbable,  however,  that  the  dietary  furnished  is  respon- 
sible for  a  large  share  of  the  evil  effects  ascribed  to  cold.  The  ab- 
sence of  sun-light  for  a  considerable  part  of  the  winter  season  may 
also  have  much  to  do  with  the  bad  influences  for  which  the  low  tem- 
perature is  held  responsible. 

Among  the  acute  effects  of  great  cold,  frost-bite  is  the  most  fre- 
quent as  well  as  the  most  serious.  Loss  of  portions  of  the  nose,  or 
ears,  or  even  of  entire  members  are  not  infrequent  results  of  frost-bite. 

In  the  arctic  regions  one  of  the  most  annoying  affections  which 
the  traveler  has  to  contend  against  is  snow-blindness,  a  severe  ophthal- 
mia produced  by  the  glare  of  the  snow.  ISTeutral-tinted  glass  goggles 
should  be  worn  as  a  preventive.^" 

Dr.  Henry  B.  Baker^^  has  placed  upon  record  a  large  mass  of 
observations  which  appear  to  indicate  that  most  of  the  acute  diseases 
of  the  respiratory  organs  are  caused  by  a  low  temperature  in  con- 
junction with  a  low  absolute  humidity.  Dr.  Baker  furnishes  numer- 
ous diagrams,  Avhich  seem  to  demonstrate  that  the  curves  for  influ- 
enza, tonsillitis,  croup,  bronchitis,  and  pneumonia  are  in  general  out- 
lines all  practically  the  same,  and  that  they  follow  the  curve  for 
atmospheric  temperature  with  surprising  closeness,  rising  after  the 
temperature  falls  and  falling  after  the  temperature  rises.  He  claims 
that  this  sameness  indicates  that  the  controlling  cause  is  one  and  the 
same  for  all  of  these  diseases,  and  that,  directly  or  indirectly,  the 
atmospheric  temperature  is  that  cause.  They  are  diseases  of  the  air- 
passages,  and  may  be  supposed  to  be  influenced  or  controlled  by  the 


'"  See  Prayer's  Narrative  of  the  Austrian  Arctic  Voyage  of  1872-74,  pp. 
250-3  and  317,  for  an  account  of  the  effects  of  cold  on  the  organism,  and  on 
the  best  prophylactic  measures  to  be  adopted.  The  Report  of  the  Surgeon- 
General  of  the  U.  S.  Navy  for  1880  also  contains  (pp.  350-8)  a  valuable  memo- 
randum by  Ex-Surgeon-General  Philip  S.  Wales,  on  Arctic  Hygiene. 

"Trans.  Ninth  International  Med.  Congress,  vol.  v. 


14  TEXT-BOOK  OF  HYGIENE. 

atmosphere  which  passes  through  them.  Although  the  curves  are 
all  similar,  yet  their  differences  still  further  support  his  view,  because 
the  order  of  succession  of  the  several  diseases  is  such  as  would  be  ex- 
pected if  caused  in  the  manner  which  he  supposes.  Thus,  croup 
and  influenza  precede  in  time  bronchitis  and  pneumonia;  the  curve 
for  bronchitis  shows  that  disease  to  respond  quicker  than  does  pneu- 
monia to  the  rise  and  fall  of  the  temperature.  He  suggests  that  the 
explanation  of  the  causation  of  these  diseases  has  not  been  grasped 
before  because  one  of  the  principal  facts  has  not  been  apprehended, 
namely,  the  fact  that  cold  air  is  always  dry  air;  on  the  contrary,  it 
has  been  generally  stated  that  when  these  diseases  occur  the  air  is  cold 
and  damp.  He  explains  that  while  the  cold  air  is  damp  relatively  it  is 
always  dry  absolutely,  and  he  thinks  that  its  bad  effects  on  the  air- 
passages  are  mainly  through  its  drying  effects,  which  can  best  be 
appreciated  by  reflecting  that  each  cubic  foot  of  air  inhaled  at  the 
temperature  of  zero,  F.  [ —  17.8°  C],  can  contain  only  i/o  grain  of 
vapor  [1.33  grammes  per  cubic  metre],  while  when  exhaled  it  is 
nearly  saturated  at  a  temperature  of  about  98°  P.  [36.5°  C],  and 
therefore  contains  about  IS^/g  grains  of  vapor  [about  43  grammes 
per  cubic  metre],  about  18  grains  of  which  have  been  abstracted  from 
the  air-passages.  Thus  cold  air  falling  upon  susceptible  surfaces 
tends  to  produce  an  abnormal  dryness  which  may  be  followed  by  irri- 
tation and  suppuration.  He  claims  that  coryza  is  sometimes  so 
caused.  Under  some  conditions  the  nasal  surfaces  are  not  susceptible 
to  drying,  the  fluids  being  supplied  in  increased  quantity  to  meet  the 
increased  demand  made  by  the  inhalation  of  cold  air.  In  that  case 
an  unusual  evaporation  of  the  fluid  leaves  behind  an  unusual  quan- 
tity of  non-volatile  salts  of  the  blood,  such  as  sodium  chloride,  and 
an  unusual  irritation  results;  he  thinks  influenza  is  the  name  com- 
monly given  to  this  condition.  The  effects  which  the  inhalation  of 
cold  air  has  on  the  bronchial  surfaces  depend  greatly  upon  how  the 
upper  air-passages  have  responded  to  the  increased  demand  for  fluids ; 
because,  if  they  do  not  supply  the  moisture,  it  must  be  supplied  by 
the  bronchial  surfaces,  in  which  case  bronchitis  results.  Finally,  if 
the  demands  for  moisture  made  by  cold  air  are  not  met  until  the 
air-cells  are  reached  pneumonia  is  produced. 

These  claims  are  partly  supported  and  partly  opposed  by  an 
elaborate  paper  by  Dr.  J.  W.  Moore.^^  According  to  the  statistics 
furnished  by  this  writer,  bronchitis  and  pneumonia  show  a  remarkable 


"The  Seasonal  Prevalence  of  Pneumonic  Fever,  Trans.  Ninth  Internat. 
Congress,  vol.  v. 


INFLUENCE  OP  TEMPERATURE  ON  HEALTH.  15 

contrast  as  to  seasonable  prevalence.  The  statistics  of  London  and 
Dublin  agree  very  closely  upon  this  point.  Bronchitis  falls  to  a  very 
low  ebb  in  the  third  or  summer  quarter  of  the  year  (July  to  Septem- 
ber, inclusive),  when  only  12  per  cent,  of  the  deaths  annually  caused 
by  this  disease  take  place  in  Dublin  and  only  11  per  cent,  in  London. 
In  the  last  or  fourth  quarter  (October  to  December  inclusive)  the 
percentage  of  deaths  from  bronchitis  rises  to  27  in  Dublin  and  30  in 
London.  The  maximal  mortality  occurs  in  the  first  quarter  (January 
to  March,  inclusive),  when  it  is  38  per  cent,  in  both  London  and 
Dublin.  In  the  second  or  spring  quarter  (April  to  June,  inclusive) 
the  bronchitic  deaths  decline  to  23  per  cent,  in  Dublin  and  21  per 
cent,  in  London. 

The  mortality  from  pneumonic  fever  is  differently  distributed 
throughout  the  year.  In  the  summer  quarter  more  than  14  per  cent, 
of  the  annual  deaths  referable  to  the  disease  are  recorded  in  Dublin 
and  more  than  15  per  cent,  in  London.  In  the  first  quarter  the  fig- 
ures are — London,  31  per  cent.;  Dublin,  31  per  cent.  In  the  second 
quarter  they  are — London,  26  per  cent. ;  Dublin,  30  per  cent.  In  the 
fourth  quarter  they  are — London,  27  per  cent.;    Dublin,  24  per  cent. 

It  therefore  appears  that  the  prevalence  and  fatality  of  pneu- 
monic fever  from  season  to  season  do  not  correspond  with  the  seasonal 
prevalence  and  fatality  of  bronchitis.  The  latter  disease  increases  and 
kills  in  direct  relation  to  the  setting  in  of  cold  weather;  it  subsides 
in  prevalence  and  fatality  with  the  advance  of  spring  and  the  advent 
of  summer.  Pneumonic  fever,  on  the  other  liand,  increases  less 
quickly  in  winter  and  remains  more  prevalent  in  spring  than  bron- 
chitis; its  maximal  incidence  coincides  with  the  dry,  harsh  winds 
and  hot  sunshine  of  spring,  when  the  diurnal  range  of  temperature 
also  is  extreme. 

Dr.  Moore  believes  that  acute  bronchitis  is  produced  directly 
by  the  influence  of  low  temperature,  while  pneumonia  requires  an 
additional  cause,  which  he  supposes  to  be  a  specific  micro-organism. 

Since  Dr.  Moore's  observations  the  specific  causes  of  pneumonia 
(the  pneumococcus)  and  influenza  (the  influenza  bacillus)  have 
been  firmly  established,  and  it  is  quite  likely  that  acute  bronchitis, 
coryza,  and  other  acute  affections  of  the  respiratory  passages  are 
caused  by  micro-organisms,  the  cold  acting  merely  as  a  predispos- 
ing factor. 


16  TEXT-BOOK  OF  HYGIENE. 


HUMIDITY  OF  THE  ATMOSPHERE  AS  CONNECTED  WITH 
CHANGES  IN   HEALTH. 

The  propagation  of  certain  acute  infectious  diseases  is  believed 
to  be  due  to  a  liigh  relative  humidity.  There  can  be  no  longer  any 
doubt  that  a  very  humid  soil  and  air,  especially  if  connected  with  a- 
variable  temperature,  are  almost  constant  factors  in  the  predispo- 
sition to  pulmonary  phthisis.  Eecent  experience  in  this  country  and 
abroad  has  shown  that  the  high  plateaus  and  mountains,  far  inland, 
where  the  soil  is  dry  and  the  relative  humidity  of  the  air  low,  are  the 
best  resorts  for  consumptives,  although  excellent  results  in  the  treat- 
ment of  tuberculosis  have  been  achieved  in  sanatoriums  located  under 
the  most  adverse  climatic  conditions. 

Of  the  effects  of  excessively  dry  air  on  health  little  definite  is 
known.  It  seems  probable,  however,  that  catarrhal  affections  of  the 
respiratory  mucous  membrane  are  more  frequent  in  a  dry  than  in  a 
humid  climate.^^ 


THE   SANITARY   RELATIONS   OF   AIR=CURRENTS. 

Primarily,  winds  or  air-currents  may  be  considered  as  favor- 
able to  health.  By  the  agitation  of  the  air  ventilation  is  secured, 
foul  air  removed  from  insanitary  places,  and  diluted  by  admixture  of 
purer  air.  But  air-currents  may  also  be  regarded  as  either  directly 
or  indirectly  unfavorably  influencing  health. 

Full  credit  is  given  by  the  public  to  cold  Avinds  and  draughts 
in  producing  catarrhs  and  rheumatic  pains.  The  progression  of  cer- 
tain infectious  diseases,  especially  malaria,  is  believed  with  good 
reason  to  stand  in  a  definite  relation  with  the  direction  of  the  wind, 
which,  if  the  latest  theory  of  the  causation  of  malaria  be  accepted, 
carries  the  infected  mosquitoes. 

Certain  local  winds  are  known  to  have  a  deleterious  effect  upon 
living  beings,  especially  when  the  latter  are  in  bad  health.  Among 
these  winds  is  the  mistral,  a  cold,  dry,  parching  northwest  wind  which 
blows  along  the  Gulf  of  Lyons.  It  brings  on  rheumatism  and  mus- 
cular pains,  and  is  said  to  excite  pleurisy  and  pneumonia  and  to  act 
unfavorably  upon  consumptives. 

The  hora  is  a  cold,  dry  wind  coming  down  from  the  Alps  and 
continuing  across  the  Adriatic. 

"  See  ante. 


SANITARY  RELATIONS  OF  AIR-CURRENTS.  17 

The  Texan  northers  are  well  known  in  the  southwestern  part  of 
the  United  States.  They  are  extremely  dry,  and  are  often  accom- 
panied by  a  sudden  fall  of  temperature.  Changes  of  28°  C.  (50°  F.) 
within  twelve  hours  are  not  infrequent  in  Western  and  Central  Texas, 
Both  man  and  beast  suffer  intensely  from  the  cold,  parching  character 
of  the  wind. 

The  sirocco  of  Northern  Africa,  Sicily,  and  Southern  Italy  has  a 
world-wide  notoriety  for  its  depressing  effect  upon  human  energy. 
The  harmattan  is  equally  noted  on  the  west  coast  of  Africa.  It  is 
hot  and  dry,  while  in  Southern  Europe  the  sirocco  is  hot  and  moist. 

The  simoon  is  a  hot,  scorching  wind  of  India,  and  is  said  to  be 
deadly  in  its  effects  upon  vegetation  and  extremely  deleterious  to  men 
and  animals  who  are  encountered  by  it.  In  Australia  and  South 
Africa  hot  winds  are  said  to  occur  which  completely  destroy  vege- 
table life  in  their  track,  and  are  often  unwholesome  in  their  effects 
upon  animal  life. 

The  evil  reputation  of  the  Alpine  fohn  is  very  well  known,  and 
neither  native  nor  traveler  is  anxious  to  encounter  it.  It  is  warm 
and  dry. 

With  reference  to  the  influence  of  electrical  conditions  of  the 
atmosphere  upon  health,  no  observations  have  been  made  which  jus- 
tify definite  conclusions.^* 

Mr.  Alexander  Buchan  and  Dr.  Arthur  Mitchell  have  analyzed 
the  influence  of  the  weather  and  season  upon  the  causation  of  disease, 
or,  rather,  upon  the  mortality  from  various  diseases.^^  Taking  the 
records  of  the  city  of  New  York  from  1871  to  1877,  it  appears  that 
the  maximum  number  of  deaths  from  small-pox  occurred  in  May, 
the  minimum  in  September.  From  measles  there  were  two  annual 
maxima  and  minima,  the  greater  in  July  and  September  and  the 
smaller  in  February  and  April.  From  scarlet  fever  the  maximum 
was  in  April,  the  minimum  in  September.  From  typhoid  fever  the 
maximum  was  from  August  to  November,  the  minimum  almost 
equally  distributed  throughout  the  rest  of  the  year;    from  diarrhea, 

"  Dr.  S.  Weir  Mitchell  has  shown,  from  the  record  of  the  case  of  CaiDtain 
Catlin,  U.  S.  A.  (American  Journal  Med.  Sci.,  April,  1877,  and  N.  Y.  Med.  Jour., 
August  25  and  September  1,  1883),  that  attacks  of  neuralgia— in  this  case,  at 
all  events — accompanied  the  progress  of  storms  across  the  continent.  Also, 
that  the  periods  of  maximum  pain  occurred  with  a  'high  but  falling  barometer 
and  increasing  absolute  humidity.  There  seems  also  to  be  some  relation  ih 
this  case  between  the  maximum  pnin  and  the  maximum  magnetic  force  as 
shown  bv  the  declinometer.  Dr.  Mitchell's  papers  are  among  the  most  valu- 
able positive  contribution  to  hygienic  meteorology,  and  desen^e  careful  study. 

^"Journal  Scottish  Meteorological  Societv.  1875-78.  (Abstract  in  Rich- 
ardson's Preventive  Medicine,  p.  5.33  ct  fieq.     Philadelphia,  1884.) 

2 


18 


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SANITARY  RELATIONS  OF  IMPURITIES  IN  AIR.  23 

the  maximum  in  July  and  August,  the  minimum  from  December  to 
March;  from  diphtheria,  tlie  maximum  in  December,  the  minimum 
in  August;^"  from  whooping-cough,  maximum  in  September  and 
February,  minimum  in  November  and  June;  for  croup  the  curves 
agree  pretty  closely  with  the  diphtheria  curves;  from  phthisis,  the 
maximum  in  March,  minimum  in  June. 

Tlie  foregoing  charts,  reproduced  by  permission  of  the  Massachu- 
setts State  Board  of  Healtli  from  the  report  of  that  body  for  1888, 
show  an  ahnost  identical  movement  of  the  mortality  from  different 
diseases  throughout  the  year.  They  exhibit  the  reported  mortality  for 
1888  and  also  for  the  six  years  from  1883  to  1888. 

From  suicide,  curiously,  the  greater  number  of  deaths  occurs  in 
May,  the  smallest  in  February.  This  is  contrary  to  the  usual  suppo- 
sition that  gloomy  weather  predisposes  to  suicide.  The  six  summer 
months — from  April  to  September — sho\\:  a  much  larger  number  of 
self-murders  than  the  remaining  half-year.  In  eleven  years,  ending 
1880,  there  were  1521  cases  of  self-destruction  in  Few  York.  Of 
these  341  occurred  during  January,  February,  and  March;  417  dur- 
ing April,  May,  and  June;  412  during  July,  August,  and  September; 
and  351  during  the  last  three  months  of  the  year.  In  Philadelphia, 
the  results  of  examination  of  the  statistics  of  suicide  for  ten  years 
are  almost  exactly  similar.  Out  of  636  cases  of  suicide,  78  occurred 
in  May,  71  in  August,  57  in  December,  54  each  in  October,  July,  and 
April,  52  in  June,  49  in  ISTovember,  44  each  in  December  and  Feb- 
rurary,  43  in  March,  and  36  in  January.^''  Dr.  Lee  is  led  to  believe 
that  "a  low  barometric  pressure,  accompanied  by  a  high  thermometric 
registry,  with  sudden  fluctuations  from  a  low  to  a  high  temperature, 
together  with  much  moisture  and  prevailing  southwest  winds,  might 
somewhat  account  for  the  frequency  of  self-murder  in  the  spring 
and  summer  months." 


THE  SANITARY  RELATIONS  OF  CHANGES  IN  COMPOSITION 
AND  OF  IMPURITIES  IN  THE  AIR. 

The  average  proportion  of  carbon  dioxide  in  the  atmosphere  is 
from  3  to  4  parts  in  10,000.     Pettenkofer^'^  places  the  maximum  limit 


^''  See  paper  on  the  Relation  of  Weather  to  Mortality  from  Diphtheria  in 
Baltimore,  by  Richard  Henry  Thomas,  in  Trans.  Med.  and  Chir.  Faculty  of 
Maryland,  188.3. 

"  Suicide  in  the  City  and  County  of  Philadelphia  durinjj;  a  Decade,  1872 
to  1881,  inclusive,  by  John  G.  Lee,  Trans.  Am.  Med.  Asso.,  vol.  xxxiii,  p.  425. 

"Quoted  in  Buck's  Hygiene  and  Public  HealJi,  vol.  i,  p.  615. 


24  TEXT-BOOK  OF  HYGIENE. 

of  carbon  dioxide  allowable  in  the  air  of  dwellings  at  7  parts  in 
10,000,  It  is  probable  that  this  limit  is  very  frequently  exceeded 
without  serious  consequences  to  health,  if  the  air  is  not  at  the  same 
time  polluted  by  organic  impurities,  the  products  of  respiration. 
Professor  William  Eipley  Nichols  found  the  air  in  a  school-room  in 
Boston  to  contain  eight  times  the  normal  proportion  of  carbon  di- 
oxide, while  Pettenkofer  found,  also  in  a  school-room,  after  the  same 
had  been  occupied  two  hours,  eighteen  times  the  normal  proportion, 
or  73  parts  in  10,000.^^  While  such  an  excess  of  this  poisonous  gas 
must  unquestionably  have  an  unfavorable  influence  upon  health,  it 
is  probable  that  the  most  serious  effects  are  due  to  the  coincident 
diminution  of  oxygen  and  the  pollution  of  the  air  by  the  products  of 
respiration  which  necessarily  take  place  during  respiration.  Carbon 
dioxide  alone  may  be  present  in  the  air  to  a  much  greater  extent  than 
above  mentioned  without  causing  any  appreciable  inconvenience.  In 
the  air  of  soda-water  manufactories  there  is  frequently  as  large  a 
proportion  as  2  per  cent,  of  this  gas  present  without  producing  any 
ill  effects  upon  those  breathing  such  an  atmosphere. 

The  amount  of  carbon  dioxide  in  the  atmosphere  is  greatest  at 
night.  It  is  also  greater  very  near  the  ground  than  at  a  distance  of 
several  feet  above  it.  As  carbon  dioxide  is  absorbed  by  the  leaves  of 
plants  during  the  day-time,  but  given  off  at  night,  the  difference  may 
partly  be  thus  accounted  for.  According  to  Fodor,^°  the  source  of  a 
large  proportion  of  the  carbon  dioxide  in  the  air  is  the  decomposition 
going  on  in  the  soil.  This  accounts  for  the  larger  percentage  of  car- 
bon dioxide  near  the  ground.  This  would  also  explain  the  variation 
of  the  proportion  of  carbon  dioxide  in  the  air  under  different  meteoro- 
logical conditions.  For  example,  it  is  found  that  during  rainy 
weather  the  carbon  dioxide  in  the  air  is  diminished.  This  is  accounted 
for  partly  by  the  absorption  of  the  carbon  dioxide  by  the  saturated 
ground,  while  at  the  same  time  the  porosity  of  the  soil  is  diminished 
and  the  escape  of  the  ground-air  prevented. 

Mr.  R,  Angus  Smith  made  a  number  of  experiments  upon  him- 
self to  determine  the  effects  of  an  atmosphere  gradually  becoming 
charged  with  the  products  of  respiration  and  perspiration.  His  ex- 
periments were  conducted  in  a  leaden  chamber  holding  5  cubic  metres 
of  air.  This  air  was  not  changed  during  the  experiment.  After  re- 
maining for  an  hour  in  this  chamber,  an  unpleasant  odor  of  organic 


^°  See  table  in  Buck's  Hygiene  and  Public  Health,  vol.  i,  p.  612. 
^°  Hygienische  Untersuchungen  ueber  Luft,   Boden  und  Wasser,   Braum- 
schweig.     1882  2te  Abth. 


SANITARY  RELATIONS  OF  IMPURITIES  IN  AIR.  25 

matter  was  perceptible  on  moving  about.  The  air,  when  agitated,  felt 
soft,  owing,  doubtless,  to  the  excess  of  moisture  contained  in  it.  The 
air  soon  became  very  foul,  and,  although  not  producing  any  discom- 
fort, the  experimenter  states  that  escape  from  it  produced  a  feeling 
of  extreme  pleasure,  like  "that  which  one  has  when  walking  home 
on  a  fine  evening  after  leaving  a  room  which  has  been  crowded."-^ 

Hammond^ ^  confined  a  mouse  in  a  large  jar  in  which  were  sus- 
pended several  large  sponges  saturated  with  baryta  water,  to  remove 
the  carbon  dioxide  as  rapidly  as  formed.  Fresh  air  was  supplied  as 
fast  as  required.  The  aqueous  vapor  exhaled  was  absorbed  by  cal- 
cium chloride.  The  mouse  died  in  forty-five  minutes,  evidently  from 
the  effect  of  the  organic  matter  in  the  air  of  the  jar.  The  presence 
of  this  organic  matter  was  demonstrated  by  passing  the  air  through 
a  solution  of  potassium  permanganate. 

The  horrible  story  of  the  'Hslack  hole"  of  Calcutta  is  familiar 
to  every  one.  Of  146  prisoners  confined  in  a  dark  cell  at  night,  23 
were  found  alive  in  the  morning.  Among  the  survivors  a  fatal  form 
of  typhus  fever  broke  out,  which  carried  off  nearly  all  of  them.  After 
the  battle  of  Austerlitz  300  prisoners  were  crowded  in  a  prison;  260 
died  in  a  short  time  from  inhaling  the  poisoned  air.  iSTumerous  other 
similar  examples  of  the  effects  of  polluted  air  are  recorded. 

Usually  the  effects  of  foul  air  are  not  so  sudden  and  striking. 
In  m.ost  instances,  especially  where  the  pollution  has  not  reached  a 
high  degree,  there  simply  results  a  general  deficiency  of  nutrition, 
which  manifests  itself  in  anemia,  loss  of  vigor  of  body  and  mind,  and 
a  gradual  diminution  of  resistance  to  disease. 

It  seems  to  be  beyond  question  that  persons  who  are  constantly 
compelled  to  inhale  impure  air,  especially  if  combined  with  an  im- 
proper position  of  the  body  or  lack  of  sufficient  or  appropriate  food, 
furnish  a  very  large  percentage  of  chronic  pulmonary  affections. 
Phthisical  patients,  in  the  overwhelming  majority  of  cases,  are 
drawn  from  the  classes  whose  occupations  keep  them  confined  in  close 
rooms.  Want  of  exercise  and  of  good  food  doubtless  aid  in  the  de- 
velopment of  the  lung  disease.  Formerly,  when  less  attention  was 
paid  to  the  proper  construction  and  ventilation  of  barracks  and 
prisons,  the  mortality  from  phthisis  among  soldiers  and  criminals  was 
much  greater  than  it  is  now.  In  animals  kept  closely  confined  the 
same  disease  claims  a  large  share  in  the  mortality. 

^Air  and  Rain,  p.  138. 

^  A  Treatise  on  Hygiene,  with  Special  Reference  to  the  Military  Service, 
by  William  A.  Hammond,  M.D.,  Surgeon-General  U.  S.  Army,  p.  170.  Phila- 
delphia, 1863. 


26  TEXT-BOOK  OF  HYGIENE. 

Near  the  end  of  the  last  century  over  one-third  of  the  infants 
born  in  the  old  Dublin  Lying-in  Hospital  died  of  epidemic  diseases. 
After  the  adoption  of  an  improved  system  of  ventilation  the  mor- 
tality fell  to  about  one-tenth  of  what  it  had  previously  been.  To 
illustrate  the  effect  of  similar  conditions  upon  the  health  of  domestic 
animals,  the  following  instance  is  cited:  Upward  of  thirty  years  ago 
a  severe  epidemic  of  influenza  in  horses  appeared  in  Boston.  At  the 
instigation  of  Dr.  H.  I.  Bowditch,  every  stable  in  the  city  was  in- 
spected, and  classified  as  "excellent,"  '^imperfect,"  or  "wholly  unfit," 
in  respect  to  warmth,  dryness,  light,  ventilation,  and  cleanliness.  It 
was  found  that  in  the  first  class  fewer  horses  were  attacked  and  the 
disease  was  milder,  while  in  the  third  class  every  horse  was  attacked 
and  the  more  severe  and  fatal  cases  occurred. 

Carbon  monoxide  is  a  very  dangerous  impurity  often  present  in 
the  air  of  living-rooms.  Being  an  ingredient  of  illuminating  gas,  as 
well  as  the  so-cal'ed  coal-gas  which  so  frequently  escapes  from  stoves 
and  furnaces,  its  dangerous  character  becomes  apparent.  Many  per- 
sons die  every  3'ear  in  this  country  from  the  inhalation  of  illuminating 
gas.  People  unacquainted  with  the  mechanism  of  gas-fixtures  fre- 
quently l)low  out  the  light  instead  of  cutting  off  the  supply  of  gas  by 
turning  the  stop-cock.  It  is  also  a  prevailing  custom  to  keep  the 
light  burning  "low"  during  the  night.  Any  considerable  variation 
of  pressure  in  the  pipes,  or  sudden  draught,  may  put  out  the  light 
and  permit  the  gas  to  escape  into  the  room,  with  fatal  effect.  Leaks 
in  pipes  or  fixtures  may  have  the  same  results.  Chronic  poisoning 
with  minute  quantities  of  illuminating  gas  is  very  common,  especially 
in  large  cities,  and  many  cases  of  obscure  anemia  and  ill-health  are 
due  to  this  cause. 

Coal-,  coke-,  or  charcoal-  fires  may  produce  serious  or  fatal 
poisoning  if  the  gas,  which  contains  a  large  proportion  of  carbon 
monoxide,  is  permitted  to  escape  into  the  room.^^  In  certain  parts  of 
Europe,  notably  in  France,  the  inhalation  of  the  fumes  of  a  charcoal 
fire  is  a  favorite  method  of  committing  suicide. 

The  gas  which  sometimes  escapes  from  the  stove  when  coal  is 
burning  has  the  following  composition : — 

Carbon  dioxide   6.75  per  cent. 

Carbon  monoxide 1-34 

Oxygen .  13.19 

Nitrogen 78.72 

^  See  paper  bv  Dr.  John  Graham  in  Transactions  of  Philadelphia  College 
of  Physicians  for  1885. 


SEWER-AIR.  27 

Sulphuretted  and  carburetted  hydrogen,  are  not  infrequently 
present  in  the  air,  especially  about  cess-pools  and  in  mines  and 
certain  manufacturing  establishments.  Sulphuretted  hydrogen  is 
generally  considered  to  be  a  violent  poison,  but  there  is  no  evidence 
that  it  is  so  unless  oxygen  is  excluded. 

Carburetted  hydrogen  is  the  so-called  "fire-damp"  of  mines, 
which  is  so  often  the  cause  of  fatal  explosions.  Its  inhalation  does 
not  seem  to  be  especially  noxious.  It  will  be  more  fully  referred  to 
in  a  succeeding  chapter. 

Variations  in  the  proportion  of  ammonia  present  in  the  air  are 
frequent.  Its  presence  is  an  indication  of  organic  decomposition  in 
the  vicinity,  but  nothing  is  known  of  the  influence  of  the  gas  itself 
upon  health,  in  the  proportion  in  which  it  is  ever  found  in  the  atmos- 
phere. 

SEWER=AIR. 

Sewer-air,  or  sewer-gas,  as  it  is  often  improperly  called,  is  a  vari- 
able mixture  of  a  number  of  gases,  vapors,  atmospheric  air,  and  solid 
particles,  and  is  derived  from  the  decomposition  of  the  animal  and 
vegetable  contents  of  sewers.  A  number  of  analyses  by  different 
chemists  have  shown  that  the  composition  of  sewer-air  is  extremely 
variable.  The  most  important  components,  in  addition  to  the  con- 
stituents of  atmospheric  air,  are:  Carbon  dioxide,  ammonia,  sul- 
phuretted hydrogen,  and  a  number  of  volatile  organic  compounds, 
which  give  to  sewage  its  peculiar  odor,  but  which  are  present  in  such 
small  quantity  as  to  prevent  accurate  determination  by  chemical 
means.  Sewer-air  may  also  contain  particulate  bodies,  bacteria,  and 
other  microscopic  organisms,  which  may  be  the  active  causes  of  in- 
fectious diseases.  Some  recent  researches  by  Carnelly  and  Haldan^ 
have  shown  that  sewer-air  usually  contains  a  less  number  of  micro- 
organisms than  the  external  air  of  cities.  The  proportion  of  carbon 
dioxide  found  was  a^so  much  less  than  was  expected.  When  the  con- 
tents of  sewers  remain  in  these  receptacles  or  conduits  long  enough 
to  undergo  decomposition,  sewer-air  is  always  present. 

The  continual  breathing  of  air  polluted  by  emanations  from  sew- 
ers often  produces  more  or  less  serious  derangements  of  health. 
Diarrhea  and  other  intestinal  affections  and  mild  cases  of  continued 
fever  have  been  frequently  noted  in  connection  with  defective  sewer- 
age, and  the  escape  of  sewer-air  into  inhabited  rooms. 

The  effluvia  from  cemeteries,  knackeries,  and  other  places  where 
the  bodies  of  animals  are  undergoing  decomposition,  are  popularly 


28  TEXT-BOOK  OF  HYGIENE. 

regarded  as  deleterious  in  their  effects  upon  health.  The  evidence  in 
favor  of  this  view  is,  however,  very  indefinite. 

Professor  Tyndall  has  shown-*  that  even  the  apparently  clearest 
air  is,  when  in  motion,  constantly  filled  with  innumerable  particles  of 
dust,  which  are  the  carriers  of  various  micro-organisms.  The  pres- 
ence of  these  particles  can  be  easily  demonstrated  by  means  of  the 
electric  light.  Every  one  has  observed  these  minute  particles  in  a 
bright  ray  of  sun-light.  Under  ordinary  conditions  these  particles 
of  dust  would,  of  course,  give  rise  to  no  trouble,  but  if  intermingled 
with  these  dust-specks  there  were  disease  germs,  then  manifestly  the 
inhalation  of  such  "dust"  would  be  dangerous.^^ 

The  quantity  of  dust  found  in  the  air  of  cities  is  much  greater 
than  in  the  country.  Tissandier  found  that  in  Paris  the  percentage 
of  dust  was  eight  to  twelve  times  greater  than  in  the  open  country. 
One-fourth  to  nearly  one-half  of  this  atmospheric  dust  is  organic, 
either  animal  or  vegetable.  A-^ery  recent  observations  have  shown  that 
in  Paris  the  air  contains  nine  or  ten  times  as  many  bacteria  in  a  given 
volume  as  the  air  at  the  observatory  of  Montsouris,  just  without  the 
city.  The  relative  proportions  of  organic  and  inorganic  particles  vary 
as  25  to  75  in  Paris,  45  to  55  in  Dublin,  and  25  to  75  in  the  open 
country.  The  organic  particles  are  either  particles  of  dead  organic 
matter,  or  minute  organisms.  The  proportion  of  the  latter  varies  in 
different  seasons,  being  the  least  in  winter  and  spring,  and  greatest 
in  summer  and  autumn.  These  organisms  are  not  necessarily  patho- 
genic, but  the  conditions  which  favor  the  proliferation  of  non-patho- 
genic bacteria  are  likely  to  promote  the  development  of  disease-pro- 
ducing ones  likewise. 

Among  the  pathogenic  micro-organisms  which  may  be  found  in 
the  atmosphere  are  spores  of  achorion  Schoenleinii,  streptococci, 
staphyloccoci,  the  bacilli  of  tuberculosis,  cholera,  and  typhoid  fever, 
and  other- micro-organisms  which  produce  disease. 

It  is  advisable  in  all  cases  to  exhaust  the  stagnant  air  in  old 
wells  and  privy- vaults  before  permitting  any  one  to  descend.  Per- 
haps the  readiest  method  of  exhausting  the  vitiated  air  in  such  places 
would  be  to  lower  heated  stones,  masses  of  hot  iron  or  pails  of  hot 
water,  to  near  the  bottom,  which  produce  a  rarefaction  of  the  air  and 
cause  it  to  ascend.  Its  place  will  then  be  occupied  by  purer  air  from 
without.     The  rarefaction  produced  by  the  explosion  of  gun-powder 


^•*  Essays  on  Floating  Matter  of  the  Air.     New  York,  1882. 
^  See  Chapter  IX,  on  Industrial  Hygiene,  for  eflfects  of  inhalation  of  dust 
in  various  industries. 


THE  EXAMINATION  OF  AIH.  29 

has  also  been  made  use  of  with  success;  but  this  has  some  objections, 
because  the  combustion  of  powder  itself  produces  gases  which  are 
noxious  if  breathed  in  large  quantity.  An  animal,  such  as  a  eat  or 
dog,  should  be  first  lowered  into  the  suspected  well  for  fifteen  or 
twenty  minutes,  in  order  to  determine  whether  the  air  at  the  bottom 
is  capable  of  sustaining  life,  before  permitting  the  workmen  to 
descend.  Similar  precautions  should  be  used  in  old,  long-unused 
mines  to  prevent  fatal  effects  from  the  so-called  "choke-damp,"  which 
is  largely  composed  of  carbon  dioxide. 

THE   EXAMINATION   OF   AIR. 

Occasions  often  arise  wherein  physicians  or  others  desire  infor- 
mation concerning  the  atmosphere  of  apartments  or  confined  spaces. 
They  have  neither  time,  apparatus,  nor,  possibly,  the  skill  necessary 
to  obtain  the  accurate  results  of  the  expert  chemist  or  bacteriologist; 
nor  do  they  require  that  the  information  which  they  seek  should  be 
so  extremely  exact. 

In  the  preparation  of  this  chapter,  therefore,  such  methods  of 
procedure  will  be  detailed  as  will  serve  to  determine,  with  reason- 
able accuracy  and  with  moderate  requirements  of  time,  expense,  or 
technical  skill,  the  hygienic  condition  of  the  substances  examined. 
The  apparatus  and  reagents  will  also  be  found,  for  the  most  part,  to 
be  cheap  and  easily  obtainable,  and  they  may  often  be  improvised 
or  prepared  from  material  already  at  hand.  Moreover,  a  little  thought 
will  show  how  a  number  of  these  methods  may  be  developed  along 
the  line  of  greater  accuracy,  should  this  be  desired,  and  the  principles 
involved  will  indicate  how  similar  examinations  may  be  made  of 
other  phases  of  the  respective  subjects  not  herein  discussed. 

The  substances  in  the  atmosphere  whose  proportions  or  charac- 
teristics it  may  be  important  to  determine  are :  the  aqueous  vapor ; 
ozone;  suspended  particles,  both  organic  and  inorganic;  living 
micro-organisms;  volatile  organic  matters,  and  the  various  gases 
given  off  as  products  of  respiration,  combustion,  etc.,  or  in  the  course 
of  certain  manufacturing  processes. 

The  proportion  of  aqueous  vapor  is  to  be  determined  by  some 
form  of  hygrometer,  such  as  Lambrecht's  polymeter,  or  from  the 
readings  of  wet-  and  dry-  bulb  thermometers,  which  readings,  when 
applied  to  Glaisher's  tables,  furnish  a  means  of  determining  the 
relative  and  the  absolute  humidity,  the  dew-point,  the  weight  of  water 
to  a  given  volume  of  air,  etc. 


30  TEXT-BOOK  OF  HYGIENE. 

The  presence  of  ozone  in  the  atmosphere  may  be  demonstrated 
by  exposing  to  the  air  strips  of  white  blotting-  or  filter-  paper  which 
have  been  saturated  with  a  solution  of  potassium  iodide  and  starch  and 
dried.  The  ozone,  decomposing  the  potash  salt,  liberates  the  iodine 
and  colors  the  starch  blue.  During  the  test  the  paper  should  not  be 
exposed  to  dust,  rain,  wind,  or  the  direct  rays  of  the  sun.  Another 
test  (Houzeau's),  perhaps  even  more  delicate,  is  to  dampen  a  strip 
of  faintly-red  litmus-paper  with  a  solution  of  the  iodide  and  dry. 
The  action  of  ozone  upon  this  is  to  liberate  the  alkaline  potash  and 
change  the  litmus  to  blue.  As  ammonia  is  the  only  other  gas  likely 
to  produce  the  same  coloration,  if  another  strip  of  the  litmus-paper, 
not  moistened  with  the  salt,  be  exposed  at  the  same  time,  whatever 
difference  in  shade  there  may  be  in  the  papers  is  due  to  the  ozone. 
An  idea  of  the  quantity  of  ozone  present  may  also  be  gained  by  com- 
paring the  shade  of  blue  given  by  either  test  with  that  produced  in 
similar  strips  of  the  starch-  or  litmus-  paper,  respectivelj^,  which 
have  been  exposed  to  certain  definite  amounts  of  ozone,  a  series  of 
such  papers  forming  a  standard  of  comparison. 

It  may  be  suggested,  for  still  another  test,  that  a  definite  quantity 
of  the  air  to  be  examined  be  drawn  through  a  faintly-acid  solution 
of  the  potassium  iodide,  phenolphthaleine  being  used  as  an  indicator. 
As  soon  as  sufficient  alkali  is  liberated  to  neutralize  the  acidity,  the 
pink  color  of  the  phenolphthaleine  will  be  developed  and  will  deepen 
as  the  proportion  of  free  alkali  increases.  Here,  also,  a  control-test 
to  eliminate  the  influence  of  ammonia  should  be  made  by  drawing  a 
similar  quantity  of  air  through  the  same  amount  of  the  solution 
minus  the  potassium  iodide.  As  before,  the  difference  in  color- 
shading  will  be  proportional  to  the  amount  of  ozone  in  the  air, 

Numerous  methods  have  been  suggested  for  the  collection  of  the 
solid  impurities  of  the  atmosphere,  varying  according  to  the  kind  or 
extent  of  examination  to  which  they  are  to  be  subjected.  If  they  are 
simply  to  be  studied  microscopically,  glass  slides  coated  with  glycerin 
and  exposed  to  the  air  will  be  sufficiently  covered  after  several  hours, 
or  they  may  be  collected  more  rapidly  by  aspirating  large  quantities 
of  the  air  against  such  slides  or  through  tubes  coated  interiorly  with 
glycerin,  as  by  means  of  Pouchet's  aeroscope  or  by  the  apparatus  de- 
vised by  Dr.  S.  G.  Dixon.  This  latter  is  especially  advantageous 
where  it  is  desired  to  collect  samples  of  dust  in  the  air  of  a  number 
of  localities  within  a  short  time,  and  consists  essentially  of  a  double 
cylinder  of  metal,  within  which  is  a  rack  carrying  a  number  of 
glycerin-  or  gelatin-  smeared  cover-glasses.    By  an  ingenious  arrange- 


THE  EXAMINATION  OF  AIR.  31 

ment  the  air  can  be  aspirated  by  means  of  a  hand-bulb  over  each  of 
these  glasses  in  turn,  the  dust  particles  being  deposited  on  the  sticky 
surface,  and  thus  the  samples  may  be  taken  from  as  many  localities  as 
there  are  cover-glasses.  Moreover,  the  specimens  may  be  mounted 
and  examined  as  they  are,  may  be  stained,  or,  if  the  glasses  be  coated 
with  gelatin  and  the  whole  apparatus  be  sterilized  ])efore  the  collec- 
tion, colonies  of  the  bacteria,  etc.,  in  the  dust  may  be  allowed  to  de- 
velop on  the  glasses  and  be  studied  in  loco  under  the  microscope. 

Another  satisfactory  method  of  collecting  suspended  particles  is  to 
draw  a  considerable  volume  of  air  very  slowly  through  a  small  quantity 
of  distilled  water  contained  in  one  or  two  wash-bottles.  The  solid 
particles  may  then  be  allowed  to  settle,  and  subsequently  be  removed 
for  microscopical  examination  by  means  of  a  pipette,  or  the  whole 
may  be  filtered  and  the  weight  of  the  dust  in  the  aspirated  air  thus 
obtained.  It  might  also  be  well,  in  the  latter  case,  to  evaporate  the 
fi'.trate  to  dryness  and  to  determine  what  proportion  of  the  residue  is 
organic  matter,  and  what  are  its  nature  and  effects  when  administered 
to  animals.  Lastly,  the  air  may  be  slowly  drawn  through  a  small 
tube  packed  with  pure  sugar,  the  sugar  afterward  being  dissolved  in 
distilled  water,  whence  the  .solid  particles  taken  from  the  air  may  be 
removed  by  means  of  a  pipette  or  by  filtration. 

The  physical  nature  of  the  particles  of  dust  thus  collected  is  to 
be  determined  by  means  of  the  microscope,  it  being  presumed  that  the 
examiner  is  sufficiently  familiar  with  the  instrument  to  recognize  at 
sight  the  more  common  materials  that  are  apt  to.  pervade  the  air  of 
occupied  apartments,  such  as  bits  of  cotton,  wool,  hair,  epithelium, 
etc.  Charring  on  ignition  will  indicate  that  the  residue  is,  at  least, 
partly  organic,  and  the  odor  of  burnt  feathers  that  it  is  nitrogen  ous 
and  probably  of  animal  origin.  Suitable  chemical  tests  will  also  de- 
termine the  presence  or  absence  of  suspected  substances.  Thus,  an 
examination  of  the  dust  by  Marsh's  or  Eeinsch's  test  may  reveal  the 
presence  of  arsenic,  and  lead  to  an  investigation  as  to  its  source. 

However,  since  Cornet  and  others  have  demonstrated  that  the 
micro-organisms  in  the  air  are,  in  general,  closely  adherent  to  the 
dust-particles,  a  bacteriological  examination  of  the  latter  will,  except 
in  special  cases,  be  of  more  importance  than  a  physical  or  chemical 
one. 

To  make  a  qualitative  bacteriological  examination  it  is  only 
necessary  to  coat  the  glass  plates  or  tubes,  already  described,  with 
nutrient  gelatin  instead  of  glycerin,  and  to  sterilize  them  before  use. 
They  are  then  exposed  to  the  air  as  before,  covered,  and  set  aside  in 


32 


TEXT-BOOK  OF  HYGIENE. 


Fig.  1. — Organic  Matters  Frequently  Present  in  Dust.  8,  Fibers 
of  Silk;  C,  of  Cotton;  L,  of  Linen;  W,  of  Wool.  F,  Feather.  St, 
Starch-granules.  Cr,  Cork.  0,  Torulse.  M,  Mycelia,  or  Threads,  of 
Mildew.  Mc,  Micrococci.  B,  Bacteria.  Lt,  Leptothricial  Filaments. 
(After  Heitzmann.)      X  500. 


a  place  of  proper  temperature  to  allow  the  colonies  to  develop  from 
the  various  micro-organisms  which  have  adhered  to  the  sticky  sur- 
faces; or  Dr.  Dixon's  apparatus,  with  gelatin-coated  glasses,  may  be 
used  in  the  manner  described. 


THE  EXAMnsTATION  OF  AIR.  33 

A  quantitative  bacteriological  examination  is  almost  as  readily 
made  by  drawing  a  given  quantity  of  air  through  a  sugar-filter,  as 
stated.  The  tube  should  not  be  too  large  in  diameter  nor  in  length, 
should  be  filled  with  pure  granulated  sugar  and  the  ends  temporarily 
plugged  with  cotton,  and  should,  of  course,  be  sterilized  before  mak- 
ing the  test.  After  the  air  has  been  drawn  through  it  the  sugar  is 
carefully  emptied  into  tubes  or  flasks  of  nutrient  gelatin,  which  have 
been  heated  just  enough  to  melt  the  gelatin,  but  not  sufficiently  high 
to  kill  the  bacteria,  etc.,  which  have  been  caught  in  the  sugar.  The 
latter  rapidly  dissolves  and  leaves  the  micro-organisms  free  to  de- 
velop in  the  gelatin,  which  may  be  poured  out  before  cooling  upon 
sterilized  glass  plates  or  into  shallow  (Petri)  dishes.  So-called  col- 
onies rapidly  develop  from  the  individual  bacteria,  and  the  total  num- 
ber of  these  colonies  may  be  assumed  to  represent  the  number  of 
micro-organisms  in  the  quantity  of  ajr  aspirated  through  the  filter. 
Moreover,  from  these  colonies  pure  cultures  may  be  made,  and  the 
nature,  etc.,  of  the  respective  microbes  determined.  To  determine  the 
quantity  of  organic  matter  in  the  air  the  most  feasible  method  is  to 
slowly  draw  a  certain  volume  of  air  through  a  given  quantity  of  twice- 
distilled  ammonia-free  water,  which  retains  not  only  all  the  volatile 
and  suspended  organic  matters,  but  also  the  gases  originating  there- 
from. The  water  is  then  to  be  tested  by  the  Wanklyn  process  for 
"free"  and  "albuminoid"  ammonia,  and,  if  desired,  by  the  Tidy- 
Forehammer  process  for  oxidizable  organic  matter,  though  it  should 
be  noted  that  in  the  latter  process  other  gases  present  in  the  air,  such 
as  sulphuretted  hydrogen,  may  help  to  decolorize  the  permanganate 
solution,  and  must  therefore  be  excluded  or  estimated  separately. 

However,  as  these  processes  are,  perhaps,  too  complex  for  the 
purpose  of  this  chapter,  and  as  it  has  been  shown  by  de  Chaumont  and 
others  that  the  organic  matter  with  which  we  are  usually  most  con- 
cerned— namely,  that  given  off  from  human  bodies  as  a  product  of 
respiration  and  like  processes — is  produced  in  quantities  proportional 
to  the  amount  of  carbon  dioxide  eliminated  in  the  same  processes,  it 
generally  suffices  for  our  purpose  to  determine  the  proportion  of  this 
gas  in  the  atmosphere,  especially  as  this  determination  is  much  more 
readily  made  than  the  foregoing  one. 

The  methods  devised  by  Wolpert  and  Angus  Smith  for  rapidly 
estimating  the  percentage  of  carbon  dioxide  have  been  materially 
simplified  by  Professor  Boom. 

Professor  Boom  has  suggested  that,  instead  of  the  special  and 
somewhat  expensive  apparatus  of  Professor  Wolpert,  a  mark  be  made 


34 


TEXT-BOOK  OF  HYGIENE. 


on  any  test-tube, — say,  one  inch  from  the  bottom.  Fix  the  bulb  of 
any  atomizer  to  a  small  glass  tube — a  capillary  one,  if  possible — suffi- 
ciently long  to  reach  the  bottom  of  the  test-tube,  and  in  such  a  man- 
ner that  a  definite  volume  of  air  is  driven  from  the  atomizer-bulb 
through  the  tube  at  each  compression  of  the  former.  In  using,  fill 
the  test-tube  exactly  to  the  mark  with  a  clear,  saturated  solution  of 
lime-water,  and  find  how  many  compressions  are  needed  in  the  out- 
door air — forcing  the  air  through  the  lime-water  each  time  and  taking 
care  not  to  draw  any  fluid  up  into  the  bulb — to  make  the  fluid  Just 
turbid  enough  to  obscure  a  pencil-mark  or  print  on  white  paper  placed 

beneath  the  test-tube  and  viewed  from 
above.  Clean  the  test-tube  thoroughly, 
and  repeat  the  process  in  the  apartment 
of  which  the  air  is  to  be  examined.  As- 
suming that  the  out-door  air  contains  the 
normal  proportion  of  carbon  dioxide, — ■ 
viz.,  0.04  per  cent., — the  percentage  in  the 
air  of  the  room  is  determined  as  follows: 
The  numljer  of  compressions  of  the 
bulb  in  the  out-door  air  :  the  number  of 
compressions  in  the  room  ::  x  :  0.04 
per  cent.,  x  representing  the  percentage  of 
carbon  dioxide  in  the  air  of  the  room. 

As  a  modification  of  the  Angus  Smith 
method,  the  author  would  suggest  the  fol- 
lowing as  being,  perhaps,  more  accurate, 
and  as  certainly  not  requiring  so  much 
apparatus,  etc. : — 

To  a  wide-mouthed  bottle,  holding 
about  a  quart  or  litre,  fit  a  doubly-per- 
forated rubber  stopper,  one  perforation  being  just  large  enough  to 
receive  the  tip  of  a  1  c.  c.  pipette,  the  other  carrying  a  small  test- 
tube,  its  mouth  opening  into  the  jar  and  close  to  the  inner  surface 
of  the  stopper.  Fill  the  bottle  and  test-tube  with  the  air  of  the 
room  by  filling  them  with  water  and  emptying;  fit  in  the  stopper, 
and  introduce,  by  means  of  a  1  c.  c.  pipette,  a  cubic  centimetre  at  a 
time  of  a  standardized  alkaline  solution,  slightly  colored  with  a  few 
drops  of  a  neutral  alcoholic  solution  of  phenolphthaleine.  Close  the 
pipette  perforation  in  the  stopper  with  a  bit  of  glass  rod  and  shake 
the  bottle  well  each  time  after  adding  the  alkaline  solution.  Con- 
tinue in  this  way  until  the  color  is  no  longer  discharged  by  the  acid 


-Ji 


Fiff.  2. 


^0 

-Air-tester. 


THE  EXAMINATION  OF  AIR.  35 

carbon  dioxide  of  the  air.  By  having  the  test-tube  fitted  in  the  stop- 
per as  above  and  inverting  the  bottle,  the  same  thickness  of  fluid  is 
observed  each  time,  and  there  is  more  accuracy  tlian  if  the  bottle  is 
used  without  the  test-tube.  In  either  ease  the  fluid  should  be  ex- 
amined by  looking  through  it  against  a  white  light  or  surface. 

ISTow,  since  the  quantity  of  the  alkaline  fluid  used  indicates  a  cor- 
respondingly definite  amount  of  carbon  dioxide, — 

the  number  of  c.  c.  of  solution  used  X  the  volume  of  C0«  each  c.  c.  represents  X  100 
the  capacity  of  the  bottle  and  test-tube  in  c.  c. — the  number  of  c.  e.  of  solution  used 

=  the  percentage  of  carbon  dioxide  in  the  air  examined. 

A  suitable  alkaline  solution  may  be  prepared  by  dissolving  ex- 
actly 4.766  grammes  (73.549  grains)  of  pure  anhydrous  sodium  car- 
bonate in  1  litre  (35.238  fluidounces)  of  distilled  water.  Each  cubic 
centimetre  of  this  solution  is  equivalent  to  a  like  volume  of  carbon 
dioxide.  To  10  cubic  centimetres  of  this  solution  add  a  few  drops  of 
a  neutral  alcoholic  solution  of  phenolphthaleine  and  dilute  with  dis- 
tilled water  to  100  c.  c.  Each  cubic  centimetre  of  the  dilute  solution 
will  now  be  neutralized  by  0.1  of  carbon  dioxide,  and,  if  used  as  sug- 
gested, should  give  close  results.  The  phenolphthaleine  is  used  as 
an  indicator,  as  it  loses  its  color  as  soon  as  the  alkalinity  of  the  soda 
solution  is  destroyed  by  the  carbonic  acid.  Example:  If  11  c.  c.  of 
the  foregoing  dilute  solution  be  nsed,  and  the  capacity  of  the  bottle 
and  test-tube  is  1153  c.  c,  then 

11  X  0.1  X  100        110 

= =  0.0963,— 

1153  —  11         1142 

the  percentage  of  carbon  dioxide  in  the  air  of  the  apartment.  The 
first  (stock)  solution  must  be  kept  in  well-filled  and  tightly-stoppered 
bottles,  and  the  dilute  solution  made  up  as  needed. 

Pettenkofer's  method  for  determining  the  percentage  of  carbon 
dioxide  in  the  air,  which  is  usually  considered  the  best,  is  as  follows : 
Into  a  large,  clean  bottle  or  Jar,  filled  with  the  air  of  the  room  as  on 
page  34,  introduce  50  c.c.  of  a  clear,  saturated  solution  of  lime  (cal- 
cium hydrate),  stopper  the  bottle,  and  shake  it  well,  so  that  the  air 
may  be  well  washed  by  the  lime-water.  This  shaking  should  be  re- 
peated at  intervals  for  several  hours,  from  eight  to  ten  hours  being 
required  for  the  lime-water  to  absorb  all  the  carbon  dioxide  in  the 
air  in  the  jar.  (However,  if  baryta — ^barium  hydrate — ^water  be  used 
instead  of  the  lime-water,  the  absorption  will  be  completed  in  an 
hour.) 


36  TEXT-BOOK  OF  HYGIENE. 

The  strength  of  tlie  lime-  (or  baryta-)  water  being  unknown  and 
variable,  it  is  determined  by  means  of  an  oxalic-acid  solution  of  such 
strength  that  1  c.  c.  corresponds  in  acidity  to  0.5  c.  c.  of  carbon 
dioxide.  Such  a  solution  is  made  by  dissolving  exactly  2.84  grammes 
(43.837  grains)  of  pure  crystallized  oxalic  acid  in  1  litre  of  freshly- 
distilled  water.  This  acid  solution  is  run  into  25  c.  c.  of  the  lime- 
water  in  a  beaker  from  a  graduated  burette,  or  pipette,  until  the  al- 
kalinity of  the  lime  is  just  neutralized,  the  neutral  point  being  indi- 
cated either  by  means  of  a  few  drops  of  a  neutral  phenolphthaleine 
solution  in  the  beaker  or  by  turmeric  paper,  the  latter  being 
colored  brown,  and  the  phenolphthaleine  retaining  its  color  as  long 
as  the  solution  is  alkaline.  When  the  lime  is  exactly  neutralized 
the  amount  of  the  acid  solution  used  from  the  burette  is  noted. 
Then  25  c.  c.  of  the  lime-water  from  the  testing-bottle  is  meas- 
ured into  a  beaker,  and  its  acidity  determined  in  the  same  man- 
ner by  means  of  the  oxalic-acid  solution.  Now,  since  part  of  the 
lime  in  the  solution  in  the  testing-bottle  has  already  been  neu- 
tralized by  the  carbonic  acid  of  the  air  therein,  it  will  require  less 
of  the  acid  solution  to  neutralize  the  lime-water  from  the  bottle  than 
it  did  to  neutralize  the  same  quantity  from  the  stock  solution,  and 
the  difference  will  indicate  the  exact  amount  of  carbon  dioxide  in  the 
air  in  the  testing-bottle.  For,  though  each  cubic  centimetre  of  acid 
solution  is  equivalent  to  only  one-half  cubic  centimetre  of  carbon  di- 
oxide, the  loss  of  alkalinity  of  only  lialf  the  lime-water  in  the  bottle 
has  been  determined,  and  the  total  loss  would  be  expressed  by  twice 
the  difference  found.  The  number  of  cubic  centimetres  of  carbon 
dioxide  in  the  air  in  the  bottle  having  been  thus  determined,  and  the 
capacity  of  the  bottle  found  by  measuring  the  quantity  of  water  it 
will  hold,  the  percentage  of  carbon  dioxide  in  the  air  is  readily  de- 
termined. For  example:  25  c.  c.  of  stock  lime-water  requires  30 
c.  c.  acid  solution,  and  25  c.  c.  of  lime-water  from  testing-bottle  re- 
quires 27  c.  c.  acid  solution;  therefore,  30  —  27  =  3  c.  c, — the 
amount  of  carbonic  acid  in  the  bottle,  which  contains,  say,  2250  c.  c. 
Then— 

3  X  100  300 

= =  0.12- 

2550  —  50       2500 

the  percentage  of  carbon  dioxide  in  the  room  at  the  current  temper- 
ature and  pressure.  It  should  be  noted  that  the  accuracy  of  all  these 
tests  is  somewhat  vitiated  by  other  acid  gases,  if  present  in  the  air, 
and  due  allowance  should  be  made  wherever  they  are  suspected. 


THE  EXAMINATION  OF  AIR.  37 

As  has  been  intimated,  baryta-water  may  be  used  in  place  of  the 
lime-water,  being  more  rapid  in  action,  but  considerably  more  ex- 
pensive, than  the  latter.  The  solution  should  be  made  of  the  strength 
of  about  7  grammes  of  crystallized  barium  hydrate  to  the '  litre  of 
distilled  water;  it  must  not  be  forgotten,  also,  that  it  is  poisonous 
when  taken  internally.  A  good  indicator,  in  addition  to  the  phenol- 
phthaleine  and  turmeric,  is  methyl-orange,  which  is  yellow  in  alka- 
line and  of  a  reddish  tint  in  acid  solutions. 

The  quantity  of  ammonia  in  the  atmosphere  may  be  determined 
by  drawing  a  certain  volume  of  air  through  ammonia-free  water  and 
then  "Nesslerizing"  the  latter,  as  in  the  Wankl}Ti  process  of  water 
analysis.  So,  also,  the  presence  and  percentage  of  other  gases,  such 
as  nitric,  hydrochloric,  sulphurous,  and  sulphuric  acid,  sulphuretted 
hydrogen,  ammonium  sulphide,  etc.,  are  obtained  by  drawing  the  air 
through  distilled  water  and  subsequently  making  the  proper  chemical 
tests.  For  instance,  the  sulphur  gas  will  darken  a  solution  of  lead 
acetate  and  ammonium  sulphide  will  change  the  blue  color  of  nitro- 
prusside  of  sodium  to  violet;  consequently,  the  air  may  be  drawn 
through  standard  solutions  of  these  reagents  and  the  resulting  col- 
oration compared  with  that  produced  by  known  quantities  of  the  re- 
spective gases. 

The  presence  of  carbon  monoxide  is  shown  by  the  darkening  of 
a  solution  of  palladium  chloride  or  sodio-chloride,  but  a  more  deli- 
cate test  is  that  of  Vogel  by  means  of  the  spectroscope,  which  will 
show  the  presence  of  as  little  as  0.03  per  cent,  of  the  gas.  In  this  test 
a  drop  of  fresh  blood  is  mixed  with  a  little  pure  water  and  the  mix- 
ture well  shaken  with  a  sample  of  the  air  in  a  jar.  Then  a  few 
drops  of  ammonium  sulphide  are  added  and  the  fluid  examined  spec- 
troscopically.  If  carbon  monoxide  is  present  the  spectrum  of  oxy- 
hemoglobin will  be  seen,  it  not  having  been  reduced  by  the  ammo- 
nium sulphide;  but  if  the  carbon  monoxide  is  not  present,  we  shall 
have  the  spectrum  of  reduced  hemoglobin. 

As  even  very  small  quantities  of  carbon  monoxide  in  the  air  are 
harmful,  it  will  not  often  be  necessary  to  make  a  quantitative  test  for 
it ;  but  should  this  be  desired,  it  can  be  done  by  passing  a  given  volume 
of  air  several  times  through  a  solution  of  subchloride  of  copper, 
wh-ich  absorbs  the  carbon  gas,  and  then  determining  the  loss  of  vol- 
ume the  air  has  suffered  by  means  of  the  eudiometer. 


38  TEXT-BOOK  OF  HYGIENE. 


PRINCIPLES   OF   VENTILATION. 

During  ordinary  respiration  an  adult  human  being  adds  900 
graromes  ^  455,500  cubic  centimetres  (14  cubic  feet)  of  carbon  di- 
oxide to,  and  abstracts  744  grammes  =  516,500  cubic  centimetres 
(16  cubic  feet)  of  oxygen  from  the  atmosphere  in  twenty-four  hours. 
Hence,  if  the  individual  were  confined  in  an  apartment  where  the 
inclosed  air  could  not  be  intermingled  by  diffusion  with  the  atmos- 
phere without,  the  proportion  of  carbon  dioxide  would  soon  become  so 
great  that  the  processes  of  life  could  not-  be  sustained,  and  the  in- 
dividual would  die.  This  result  would  be  reached  even  sooner  than 
the  point  here  mentioned,  for  the  organic  matter  exhaled  from  the 
lungs  and  the  surface  of  the  body  would  increase  the  poisonous  con- 
dition of  the  air  even  more  than  the  carbon  dioxide  given  off.  It  is 
easily  seen,  therefore,  how  important  the  study  of  the  principles  and 
practice  of  ventilation  becomes  in  hygiene.  In  this  chapter  only  the 
principles  underlying  this  subject  can  be  definitely  stated.  Practical 
details  will  be  more  fully  given  in  the  chapters  devoted  to  dwellings, 
schools,  hospitals,  etc. 

It  is  generally  accepted  among  sanitarians  that  the  presence  of 
.07  per  cent  (7  parts  in  10,000)  of  carbon  dioxide  in  the  air  indi- 
cates the  greatest  amount  of  organic  impurity  (from  respiration  or 
combustion)  consistent  with  the  preservation  of  health.  As  each  in- 
dividual gives  off  from  his  lungs,  in  the  process  of  respiration,  316 
cubic  centimetres  of  carbon  dioxide  per  minute,  the  diffusion  in  the 
air  surrounding  him  must  be  sufficiently  rapid  to  keep  the  air  to  be 
breathed  at  the  standard  of  .07  per  cent,  above  mentioned. 

Adopting  this  as  the  standard  of  maximum  impurity  allowable, 
90  cubic  metres  of  fresh  air  per  hour  will  be  needed  for  each  indi- 
vidual to  keep  him  supplied  with  pure  air.  This  is  for  a  person  in 
a  state  of  health ;  in  cases  of  disease  a  more  rapid  change  of  air  will 
be  necessary  to  keep  that  surrounding  the  patient  in  a  state  of  purity. 

Ventilation  is  defined  by  Worcester  as  "the  replacement  of  nox- 
ious or  impure  air  in  an  apartment,  mine,  or  inclosed  space  by  pure, 
fresh  air  from  without."  By  Dr.  Parkes  the  term  is  restricted  to 
"the  removal  or  dilution,  by  a  supply  of  pure  air,  of  the  pulmonary 
and  cutaneous  exhalations  of  men  and  the  products  of  combustion  of 
lights  in  ordinary  dwellings,  to  which  must  be  added,  in  hospitals, 
the  additional  effluvia  which  proceed  from  the  persons  and  discharges 
of  the  sick.     All  other  causes  of  impurity  of  air  ought  to  be  ex- 


PRINCIPLES  OF  VENTILATION.  39 

eluded  by  cleanliness,  proper  removal  of  so' id  and  liquid  excreta,  and 
attention  to  the  conditions  surrounding  dwellings."-*' 

A  proper  system  of  ventilation  must  take  into  consideration  the 
cubic  space  of  the  apartment  or  building  to  be  ventilated,  the  num- 
ber of  persons  ordinarily  inhalnting  this  space,  whether  constantly  or 
only  temporarily  occupied,  and  certain  other  collateral  elements,  such 
as  the  character  of  the  building  to  be  ventilated,  its  exposure,  neces- 
sity  for   artificial   heating,   etc. 

The  amount  of  cubic  space  that  must  be  allowed  to  each  indi- 
vidual is  determined  by  the  rapidity  with  which  fresh  air  must  be 
supplied  in  order  to  keep  that  surrounding  the  individual  at  the 
standard  of  less  than  .07  per  cent,  of  carbon  dioxide.  For  example, 
in  a  space  of  3  cubic  metres,  the  air  must  be  changed  thirty  times  in 
an  hour  in  order  to  prevent  the  carbon  dioxide  exceeding  the  above 
proportion;  that  is  to  say,  to  allow  90  cubic  metres  of  air  to  pass 
through  that  space  in  the  time  mentioned.  This  would  create  an 
uncomfortable,  if  not  injurious,  draught.  If  the  space  contained  30 
cubic  metres,  the  air  would  need  renewal  only  three  times  an  hour. 

A  space  of  15  cubic  metres  could  be  kept  supplied  with  pure  air 
without  perceptible  movement  if  all  the  mechanical  arrangements  for 
changing  the  air  were  perfect;  but  such  perfection  is  rarely  attain- 
able, and  hence  there  would  be  either  draughts  or  insufficient  venti- 
lation in  such  a  small  "initial  air-space,"  as  it  is  termed.  The  initial 
air-space  should,  therefore,  be  not  less  than  30,  or,  better,  40  cubic 
metres.  The  air  of  this  space  could  be  changed  sufficiently  often  to 
keep  it  at  its  standard  of  purity  without  creating  unnecessary 
draught.  For  sick  persons  this  should  be  doubled.  In  hospitals, 
therefore,  the  cubic  air-space  allowed  to  each  bed  should  be  not  less 
than  60  to  80  cubic  metres. 

As  stated,  the  purposes  for  which  the  building  or  apartment  to 
Ije  ventilated  is  employed  require  differences  in  the  cubic  space  and 
in  the  volume  of  fresh  air  supplied.  In  Table  III  (page  40)  Morin 
gives  the  cubic  space  for  various  purposes. 

These  figures  are  not  excessive  from  a  sanitary  standpoint, 
although  few  buildings  meet  the  requirements  here  set  down. 

The  source  of  the  air  supplied  must,  of  course,  be  capable  of 
yielding  pure  air.  It  should  not  be  drawn  from  damp  cellars  or  base- 
ments, or  from  tbe  immediate  vicinity  of -sewers  or  drains.    Air  taken 


'''M;inu;i,l  of  Practical  Tlygiene,  6th  cd.,  New  York,  vol.  i,  p.  157. 


40  TEXT-BOOK  OF  HYGIENE. 


Table  III 

Hospital  wards  for  ordinary  cases 60-70  cubic  metres. 

Hospital  wards  for  surgical  and  obstetrical  cases.  .   100  "  " 

Hospital  wards  for  contagious  diseases 150  "  " 

Prisons 50 

(    ordinary  occupations    60  " 

(   unhealthy  occupations  100  "  " 

S   during  the  day    30  "  " 

Barracks        i    ^     ■       .-,        ■  ■..  ^n  -n      "  " 

<   during  the  night 40-o0 

Theatres    40-50  " 

Assembly  rooms  for  long  receptions 60  "  " 

Assembly  rooms  for  brief  receptions 30  "  " 

Primary   schools    12-15  "  " 

Higher   schools    25-30  "  '     "' 

Stables   180-200  " 

from  such  places  is  little  better  for  respiration  than  that  which  it 
replaces  in  the  apartments  to  be  ventilated. 

Ventilation  may  be  accomplished  either  with  or  without  arti- 
ficial aids.  In  buildings  or  rooms,  used  as  habitations,  natural  ven- 
tilation (with,  perhaps,  the  simplest  mechanical  aids)  is  made  use 
of  almost  entirely.  In  large  buildings,  such  as  churches,  theatres, 
schools,  or  in  ships  and  mines,  one  of  the  artificial  systems  must  be 
adopted  if  efficient  ventilation  is  desired. 

Natural  ventilation  takes  place  by  diffusion,  by  perflation,  and 
in  consequence  of  inequality  of  atmospheric  pressure.  By  difl'usion 
is  meant  the  slow  and  equable  entrance  of  air  from  without  and  exit 
from  within  a  room  through  the  walls  or  ill-made  joints  without  the 
influence  of  wind-currents.  In  an  occupied  room  this  is,  however, 
insufficient  to  keep  the  air  pure,  because  many  of  the  organic  im- 
purities of  respired  air  are  molecular,  and,  therefore,  incapable  of 
making  their  way  out  of  the  rooms  through  the  walls. 

Perflation  means,  literall}^,  "T^lowing  through,"  and,  if  the  di- 
rection and  force  of  air-currents  could  be  regulated,  this  would,  with 
simple  mechanical  arrangements,  be  an  efficient  means  of  ventilation. 
However,  the  uncertainty  of  the  force  and  direction  of  the  wind  makes 
this  method  of  ventilation  untrustworthy  except  in  warm  weather. 

Unequal  pressure  between  the  air  in  a  room  and  that  without 
is,  within  certain  limits,  an  efficient  means  of  ventilation,  and  is  usu- 
ally relied  upon  in  ordinary  apartments.  When  the  air  in  a  room 
is  heated  above  the  temperature  of  the  external  air,  either  by  a  fire, 
lights,  or  by  the  presence  of  a  number  of  persons  in  the  room,  it  ex- 


PRINCIPLES  OF  VENTILATION.-  41 

pands,  and  part  of  it  finds  its  way  out  through  numerous  crevices 
and  bad  joints  found  in  all  buildings.  The  air  which  remains  be- 
ing less  dense  than  the  external  air,  the  latter  enters  the  room  by 
various  openings,  until  the  equality  of  pressure  is  re-established. 
But  as  the  heating  of  the  enclosed  air  continues,  the  process  is  mom- 
entarily repeated  and  becomes  continuous. 

Although  the  impurities  of  respired  air  (carbon  dioxide,  or- 
ganic matter)  are  heavier  than  the  air  itself  at  the  same  temperature, 
it  is  a  familiar  fact  that  the  most  impure  air  in  an  occupied  room 
is  always  found  near  the  ceiling,  the  impurities  being  carried  up- 
ward with  the  heated  air,  and  that  the  pure  air  from  without,  being 
colder,  fills  the  lower  part  of  the  room. 

If  the  cold,  outside  air  were  to  be  admitted  at  the  bottom  of  the 
room,  and  means  allowed  for  the  escape  of  the  hot  air  at  the  top,  the 
conditions  of  the  old  health-maxim,  to  "keep  the  feet  warm  and  the 
head  cool,"  would  be  reversed.  This  would  be  no  less  uncomfortable 
than  unwholesome.  In  all  plans  for  natural  ventilation,  therefore, 
provision  must  be  made  to  secure  a  gradual  diffusion  of  the  cold,  out- 
side air  from  above,  or  to  have  it  warmed  before  it  enters  the  room. 
With  a  large  chimney  as  an  aspirating  shaft,^^  with  flues  at  the  top 
and  bottom  of  the  room,  and  openings  in  the  walls  of  the  room  near 
the  ceiling  to  admit  fresh  air,  sufficient  ventilation  can  be  usually 
secured  in  cold  weather,  in  a  room  not  overcrowded. 

When  a  room  is  heated  by  a  furnace,  the  fresh  air  is  warmed 
before  it  is  introduced,  and  the  foul  air  escapes  either  through  a  ven- 
tilating shaft,  a  ventilator  in  the  window  or  wall,  or  through  the 
numerous  fissures  and  other  orifices  which  defective  carpentering 
always  leaves  for  the  benefit  of  the  health  of  the  occupants. 

The  following  rules  for  the  arrangement  of  a  system  of  natural 
ventilation  are  modified  and  condensed  from  Parkes-^ : — 

The  apertures  of  entrance  and  of  exit  for  the  air  should  be 
placed  far  enough  apart  to  permit  thorough  diffusion  of  the  fresh  air. 

When  the  air  is  brought  into  a  room  through  slits  or  tubes  in  the 
walls  near  the  ceiling  the  current  should  always  be  deflected  upward 
by  an  inclined  plane,  in  order  to  prevent  a  mass  of  cold  air  from 
descending  over  the  shoulders  of  the  occupants  and  chilling  them. 

The  air  must  be  taken  from  a  pure  source. 

^Of  course  there  is  really  no  such  tiling  as  a  real  aspiration,  or  "sucking 
out"  of  the  air  through  the  chimney  or  so-called  "aspirating  shaft."  The 
upward  movement  of  the  air  in  the  shaft  is  due  to  its  displacement  by  the 
colder  or  denser  air  entering  the  room. 

^Manual  of  Practical  Hygiene,  6th  ed.,  New  York,  vol.  i,  p.  177. 


42  •     TEXT-BOOK  OF  HYGIENE. 

The  inlet-tubes  should  be  short,  and  so  made  as  to  be  easily 
cleansed,  otherwise  dirt  lodges  and  the  air  becomes  impure. 

Inlets  should  be  numerous  and  small,  to  allow  a  proper  distribu- 
tion of  the  entering  air. 

Externally,  the  inlets  should  be  partially  protected  from  the 
wind,  to  prevent  strong  draughts;  they  should  also  be  provided  with 
valves  to  regulate  the  supply  of  air. 

If  the  air  cannot  be  warmed,  the  inlets  must  be  near  the  ceiling ; 
if  it  can  be  heated,  it  ma}^  enter  near  the  floor. 

The  air  may  be  warmed  by  passing  it  through  boxes  containing 
hot  water  or  steam  coils,  by  passing  it  through  chambers  around 
grates  or  stoves,  or  heating  it  in  a  furnace. 

In  towns  or  manufacturing  districts  the  air  should  be  filtered 
before  allowing  it  to  enter  the  room.  Thin  flannel  or  muslin  spread 
over  the  openings  answers  very  well  as  filtering  material. 

Outlets  should  be  placed  at  the  highest  point  of  the  room  and 
should  be  protected  from  the  weather.  An  opening  into  the  chimney 
near  the  ceiling  will  answer  well  in  many  cases. 

In  one-story  buildings,  ridge-ventilators  make  the  best  outlets. 
The  entrance  of  snow  and  rain  must  be  prevented  by  suitable  ar- 
rangements. 

A  small  space  or  slit  between  the  horizontal  bars  of  the  upper 
and  lower  window-sash  will  admit  sufficient  air  in  a  proper  direc- 
tion in  small  rooms,  even  when  the  window  is  shut. 

In  all  rooms,  howsoever  ventilated,  doors  and  windows  should 
be  often  opened  to  permit  a  thorough  -flushing  of  the  interior  with 
fresh  air. 

For  large  buildings,  hospitals,  schools,  theatres,  ships,  and  mines, 
two  systems  of  artificial  ventilation  are  in  use.  One  operates  by 
extracting  the  foul  air  by  means  of  fans,  the  other  by  forcing  in 
fresh  air,  allowing  the  impure  air  to  find  its  way  out  as  best  it  may. 

Eotating  cowls  on  the  tops  of  chimneys  may  be  used  to  increase 
the  aspirating  power  of  the  air;  in  this  way  the  natural  force  of  the 
wind  may  be  utilized  for  ventilation  of  rooms  or  buildings  of  mod- 
erate size. 

Further  details  upon  the  practical  application  of  these  prin- 
ciples will  be  given  in  succeeding  chapters  of  this  work. 


QUESTIONS  TO  CHAPTER  I. 

AIR. 

Wliat  is  the  composition  of  the  atmospheric  air?  Is  the  mixture  a 
chemical  or  mechanical  one?  What  constituent  is  the  most  constant  in  pro- 
portion, and  what  ones  most  variable?  What  are  the  causes  and  limits  of 
variation  in  the  composition  of  the  air?  Has  this  variation  any  effect  upon 
health? 

How  is  the  general  uniformity  of  composition  maintained?  What  is  the 
relation  of  the  oxygen  and  carbon  dioxide  to  plant  and  animal  life  and  to  one 
another? 

What  is  the  depth  of  the  atmosphere?  What  is  its  weight,  and  how  is 
this  measured?  How  may  you  determine  the  altitude  of  any  place  above  the 
sea -level? 

What  effect  has  temperature  on  barometric  pressure?  What  effect  has 
moisture  and  why?  Whence  does  the  air  derive  its  warmth?  Where  is  the 
atmosphere  warmest? 

What  is  the  relation  between  the  temperature  and  humidity  of  the  air? 
"What  is  meant  by  "absolute"  and  "relative"  humidity?  How  is  each  always 
designated?    What  is  meant  by  "saturation"? 

What  causes  motion  in  air  or  wind?  What  conditions  of  the  atmosphere 
probably  have  relation  to,  or  influence  upon,  disease?  Why  should  a  sanitarian 
be  a  practical  meteorologist? 

What  are  the  physiological  effects  of  diminution  of  atmospheric  pressure  ? 
What  may  aggravate  these  effects?  To  what  are  they  due?  Can  the  human 
body  become  accustomed  to  them?  What  name  is  given  to  this  physiological 
disturbance?  What  diseases  will  probably  improve  in  a  rarefied  atmosphere, 
and  what  ones  will  not? 

What  are  the  effects  of  increased  atmospheric  pressure  upon  the  organ- 
ism? Is  there  any  danger  of  fatal  results?  Have  the  diurnal  variations  of 
pressure  any  effect  upon  the  body  in  health  or  in  disease? 

What  effect  has  high  temperature  upon  health?  What  diseases  are  more 
frequent  in  hot  weather  and  in  hot  climates? 

What  peculiar  affection  seems  to  be  caused  or  favored  by  long-continued 
exposure  to  cold?  What  are  some  of  the  acute  effects  of  cold?  "What  effect 
has  the  relative  humidity  in  the  production  of  these  diseases?  Indicate  and 
explain  a  possible  relationship  of  causation  between  coryza  or  influenza,  bron- 
chitis and  pneumonia.  Is  this  altogether  substantiated  by  statistics?  Is  Low 
temperature  the  only  cause  of  pneumonia? 

What  part  has  the  relative  humidity  in  the  production  of  certain  dis- 
eases ? 

"Wliat  is  the  general  rule  as  to  the  effect  of  winds  or  air-currents  upon 
health?     Name  some  apparent  exceptions  to  this  rule.     Has  the  season  any 

(43) 


44  TEXT-BOOK  OF  HYGIENE. 

thing  to  do  with,  the  morbidity  and  mortality  from  different  diseases?  Give 
examples. 

Wliat  is  the  average  proportion  of  carbon  dioxide  in  the  atmosphere? 
What  should  be  the  maximum  limit  permissible  in  dwellings?  Is  this  limit 
often  exceeded?  When  exceeded,  to  what  are  the  evil  effects  upon  health 
probably  due?  How  much  carbon  dioxide  alone  may  be  present  in  the  atmos- 
phere without  producing  any  apparent  ill  effects? 

"\^Tien  and  Avhere  in  the  out-door  atmosphere  is  the  proportion  of  carbon 
dioxide  greatest?     In  what  way  may  this  be  explained? 

T\liat  are  the  products  of  respiration  and  perspiration,  and  which  of 
these  is  most  harmful  to  health?  What  evidence  have  we  to  that  effect? 
Have  we  anj'  evidence  that  the  respiratory  carbon  dioxide  alone  is  harmful  to 
health?  'WTiere  there  is  a  moderate  degree  of  respiratory  pollution,  what 
are  some  of  the  symptoms  usually  produced  thereby?  In  the  production  of 
what  especial  disease  has  impure  air  a  decidedly  causative  influence? 

WTiich  is  the  more  dangerous  to  health,  carbon  monoxide  or  carbon  diox- 
ide? Of  what  gases  is  the  former  an  ingiedient?  How  does  it  produce  its 
harmful  effects? 

Have  sulphuretted  and  carburetted  hydrogen  any  effect  upon  health?  If 
so,  in  what  proportions  must  they  be  in  the  atmosphere?  Has  ammonia,  in  the 
proportion  in  which  it  is  usually  found  in  the  atmosphere,  any  bad  effect  upon 
health? 

^Miat  is  sewer-air  or  sewei'-gas,  and  what  are  some  of  its  constituents? 
In  what  way  may  it  be  the  cause  of  infectious  disease?  Will  the  continued 
breathing  of  air  polluted  with  sewer-gas  affect  health,  and,  if  so,  what  symp- 
toms may  be  caused  thereby? 

Is  there  any  positive  evidence  that  the  emanations  from  cemeteries,  bone- 
yards,  etc.,  are  harmful  to  health? 

"\Miat  diseases  may  be  produced  by  the  inhalation  of  pathogenic  micro- 
organisms carried  by  the  air? 

How  may  the  presence  of  ozone  in  the  air  be  demonstrated?  Upon  what 
does  the  test  depend?  How  might  an  approximate  quantitative  test  of  ozone 
be  made? 

How  may  the  suspended  impurities  in  the  atmosphere  be  collected  for 
examination?  Which  method  requires  the  least  apparatus,  etc.?  How  may 
the  character  and  nature  of  the  suspended  particles  be  determined?  How  may 
a  quantitative  bacteriological  examination  be  made?  AMaat  are  some  of  the 
advantages  of  Dr.  Dixon's  apparatus?  Of  the  sugar-filter  method?  How  may 
pure  cultures  of  micro-organisms  in  the  air  be  obtained? 

How  may  the  quantity  of  organic  matter  in  the  air  be  determined?  Why 
do  we  determine  the  proportion  of  carbon  dioxide  in  the  air?  What  is  Wol- 
pert's  method  for  finding  the  percentage  of  this  gas,  and  how  may  this  method 
be  simplified?  Upon  what  does  this  test  depend?  "What  precautions  must 
be  obseiwed  in  making  the  test  ?  What  is  the  Angus  Smith  method  for  deter- 
mining the  proportion  of  carbon  dioxide?  How  may  it  be  improved?  What 
is  the  use  of  the  phenolphthaleine  in  the  solution?  How  is  the  percentage 
of  carbon  dioxide  calculated?     How  is  the  alkaline  solution  to  be  prepared? 

Upon  what  does  Pettenkofer's  method  depend?  \"\Tiat  apparatus  and 
reagents  are  required?    Why  must  the  lime-water  be  standardized  each  time? 


QUESTIONS  TO  CHAPTER  I.  45 

What  is  the  value  of  the  oxalic-acid  solution?  What  are  some  good  indicators 
to  use  in  this  test?  Why  is  just  twice  the  volume  of  lime-water  introduced 
into  the  bottle  that  is  afterward  taken  from  it  and  tested?  What  are  some  of 
the  advantages  and  disadvantages  of  baryta-Avater  in  comparison  with  lime- 
water? 

How  may  the  quantity  of  ammonia  in  the  atmosphere  be  determined? 
How  may  the  presence  of  other  gases  be  shown?  ViTiat  is  the  usual  test  for 
carbon  monoxide?  Upon  what  is  Vogel's  test  based?  Is  it  a  delicate  one? 
Why  is  it  usually  not  necessary  to  make  a  quantitative  examination  of  the 
carbon  monoxide? 

VentUation. — How  much  oxygen  does  an  adult  human  being  at  rest  ordi- 
narily take  from  the  air,  and  how  much  carbon  dioxide  does  he  add  to  it  in 
twenty-four  hours?  What  percentage  of  carbon  dioxide  in  the  air  indicates 
the  greatest  amount  of  organic  impurity  from  respiration,  etc.,  consistent  with 
health?  How  much  fresh  air  per  hour  is,  therefore,  needed  by  each  individual 
to  maintain  this  state  of  purity?  Will  sick  persons  need  more  fresh  air  than 
the  well?    Why? 

What  is  meant  by  ventilation?    What  should  be  excluded  from  the  term? 

What  matters  must  a  proper  system  of  ventilation  consider?  What  gov- 
erns the  amount  of  cubic  space  that  can  be  allotted  to  each  individual?  What 
should  be  the  minimum  air-space  for  the  well,  and  what  for  the  sick?  What 
should  be  the  floor-space  for  each  person,  and  why?  From  what  kind  of  a 
source  must  the  air  for  a  ventilation  supply  be  taken? 

What  is  the  difference  between  natural  and  artificial  ventilation?  What 
are  the  forces  acting  to  produce  natural  ventilation?  What  is  meant  by  dif- 
fusion? Why  is  it  insufficient  for  ventilating  an  occupied  room?  What  is 
meant  by  perflation?  Why  cannot  it  be  used  alone  for  ventilation?  Upon 
what  does  the  inequality  of  atmospheric  pressure  depend?  Why  is  it  the  most 
valuable  of  the  forces  of  natural  ventilation? 

In  what  part  of  an  occupied  room  is  the  most  impure  air  found,  and 
why? 

What  precautions  must  be  observed  in  all  plans  for  natural  ventilation? 
What  makes  the  air  from  a  room  pass  up  a  chimney?  When  a  room  is  heated 
by  a  hot-air  furnace,  how  does  the  foul  or  used  air  escape?  What  rules  may 
be  laid  down  for  the  arrangement  of  a  system  of  natural  ventilation? 

Where  should  the  fresh-air  inlets  of  a  room  be  located?  How  may  the 
air  be  warmed  before  bringing  it  into  the  room?  How  should  the  inlet-tubes 
be  arranged?    Where  should  the  outlets  of  a  room  be  located? 

What  systems  of  artificial  ventilation  may  be  employed  for  large  build- 
ings or  rooms  ?  By  what  appliances  may  we  make  use  of  winds  for  ventilating 
purposes? 


CHAPTER  II. 

WATER. 

Physiologists  teach  that  nearly  two-thirds  of  the  tissues  of  the 
animal  body  consist  of  water.  Inasmuch  as  this  water  is  constantly 
being  lost  by  evaporation  from  the  skin,  exhalation  by  the  lungs,  and 
excretion  through  various  organs,  it  is  evident  that  the  loss  must  be 
constantly  supplied  if  the  functions  of  life  shall  be  properly  per- 
formed. 

It  appears  probable  that  certain  diseases  are  at  times  spread 
through  the  agency  of  insufficient  or  impure  drinking-water.  It  is 
therefore  a  matter  of  very  great  importance  to  have  a  definite  knowl- 
edge of  what  constitutes  a  pure  and  sufficient  supply  of  water,  and 
how  best  to  secure  it,  to  be  able  to  detect  its  conditions  of  purity  and 
impurity,  and  to  know  how  to  maintain  the  former  and  avoid  the 
latter.  It  will  be  necessary  to  consider  in  detail,  therefore,  the 
quantity  of  water  required  by  each  individual  for  the  maintenance 
of  health,  the  sources  whence  water  is  obtained,  how  it  should  be  col- 
lected and  stored  to  the  best  advantage,  the  impurities  likely  to  be  con- 
tained in  it,  and  the  methods  of  keeping  it  pure,  or  of  purifying  it 
when  it  has  become  polluted  or  vitiated  in  any  manner. 

THE  QUANTITY  OF  WATER  REQUIRED  BY  HUMAN 
BEINGS. 

Dr.  Parkes,  after  a  number  of  experiments,  concluded  that  a 
man  of  the  English  middle  class,  "who  may  be  taken  as  a  fair  type  of 
a  cleanly  man  belonging  to  a  fairly  cleanly  household,"  uses  about 
twelve  gallons  of  water  per  day.  This  covers  all  the  water  needed, 
including  a  daily  sponge  bath.  Dr.  DeChaumont  estimates^  that  16 
gallons  should  be  the  daily  allowance.  By  order  of  the  British  War 
Department,  15  gallons  of  water  are  allowed  to  each  soldier  daily. 
In  very  many  instances  this  quantity  cannot  be  furnished,  but  in 
such  cases  there  necessarily  results  some  deficiency  in  cleanliness.  It 
is  probable  that  among  the  poorer  classes,  especially  where  a  large 
supply  of  water  is  not  convenient,  the  quantity  used  is  not  over  one- 
fourth  of  the  above  estimate. 


^  Parkes'  Hygiene,  6th  ed.,  New  York,  vol.  i,  p.  5. 
(46) 


QUANTITY  OF  WATER  REQUIRED. 


47 


head: 


Household 


Parkes    and   Kenwood^    give   the    average   daily   quantities    per 

Table  IV. 

Fluids  as  drink  0.33 

Cooking   0.75 

Personal  ablution  5.00  to  10.00 

Utensils  and  house  washing 3.00 

Clothes  washing   (laundry) 3.00 

Water  closets 5.00 

Trade  and  manufacturing   5.00 

Cleansing  streets    5.00 

Public  baths  and  fountains 5.00 

Flushing  and  cleansing  sewers 5.00 

Extinguishing  fires 5.00 

27.08  to  32.08 


Municipal    < 


In  American  cities  the  daily  consumption  is  much  greater,  as 
seen  from  the  following  table: — 

Table  V. 

Showing  Consumption  of  Water  in  105  American  Cities. 


City  and  State 


Akron,  Ohio    p 

Altoona,  Pa m 

Anderson,  Ind m 

Atlantic  City,  N.  J m 

Augusta,    Georgia    m 

Atlanta,    Georgia     m 

Battle   Creek,   Mich m 

Boston,  Mass m 

Buffalo,  N.   Y m 

Burlington,    Iowa    p 

Binghamton,  N.  Y m 

Brocton,  Mass m 

Camden,  N.  J m 

Cambridge,   Mass m 

Cincinnati,    Ohio    m 

Chicago,    111 m 

Cleveland,   Ohio    m 

Charleston,  S.  C m 

Council   Bluffs,  Iowa p 

Denver,    Colo p 

Detroit,    Mich m 

Danville,   111 p 

Davenport,    Iowa    p 

Dayton,   Ohio    m 

Duluth,   Minn m 

Danbury,   Conn m 

Easton,    Pa p 


D  ily 

Per 

Population 

Consumjition 

Capita3 

Gallons 

Gallons 

46,733 

'03) 

7,500,000 

137 

52,000 

'03) 

4,500,000 

90 

20,178 

'00) 

2,000,000 

66 

32,272 

'03) 

5,250,000 

138 

41,283 

'03) 

5.500.000 

110 

96.550 

'03) 

7,500,000 

60 

18,563 

'00) 

1.133.000 

60 

594,618 

'03) 

83,000,000 

145 

381,403 

'03) 

125,000,000 

320 

23,201 

'00) 

2,000,000 

80 

39,647 

'00) 

50,000 

'05) 

2,000,000 

36 

79,811 

'00) 

12,000,000 

160 

98,444 

'03) 

8,775,000 

89 

340,000 

'03) 

48,536,000 

137 

1,873,880 

'03) 

175,000,000 

200 

444,600 

'05) 

61,572,000 

138 

55,807 

'00) 

3,070,000 

55 

25,802 

'00) 

2.500,000 

85 

147,111 

'03) 

32,000,000 

200 

369,805 

'05) 

60,212,5.39 

108 

16,354 

'00) 

2,500,000 

157 

37,768 

'03) 

4,000,000 

100 

92,716 

'03) 

7,000,000 

66 

57,397 

'03) 

5,000,000 

85 

16,537 

'00) 

2,000.000 

125 

23,238 

'00) 

2,000,000 

87 

■Hygiene  and  Public  Health,  1902. 

'  The  per  capita  is  based  on  the  number  of  consumers. 


48 


TEXT-BOOK  OF  HYGIENE. 


Table  V. —  ( Continued. ) 
Showing  Consumption  of  Water  in  105  American  Cities. 


City  and  State 


Elmira,   N.   Y p 

Erie,   Pa m 

Evansville,  Ind m 

Fort  Smith,  Ark p 

Fall   River,   Mass m 

Fond   du  Lac,   Wis p 

Fort  Wayne,   Ind m 

Fitchburg,   ]\Iass ni 

Grand  Rapids,   j\Iich m 

Harrisburg,  Pa m 

Hartford,    Conn m 

Haverhill,   Mass m 

Henderson,   Ky m 

Houston,    Texas     p 

Holyoke,  Mass m 

Indianapolis,    Ind p 

Johnstown,  Pa.    .  . p 

Jamestown,    N.    Y p 

Kansas   City,  Mo m 

Kingston,  N.  Y m 

Lowell,  Mass m 

Los   Angeles,   Cal m 

Lynn,   Mass m 

Louisville,  Ky m 

Lincoln,   Neb m 

Manchester,  N.  Y m 

McKeesport,   Pa m 

Minneapolis,  Minn m 

Milwaukee,   Wis m 

Memphis,    Tenn p 

]\Iuskegon,   Mich m 

Norfolk,  Va m 

New  Bedford,   Mass m 

New  Orleans,  La p 

New  Albany.  Ind. p 

Nashville,    Tenn m 

New  Haven,  Conn p 

Oshkosh,  Wis p 

Paterson,  N.  J p 

Peoria,   111 m 

Pittsburg,  Kans p 

Portland,   Me p 

Portland,   Ore m 

Quincy,    Mass m 

Quincy,    111 p 

Reading,  Pa m 

Rochester,   N.   Y m 

Roanoke,  Va p 

Rock   Island,  111 m 

Rushville,  Ind m 

Richmond,  Va m 

Salem,   Mass m 

Saginaw,   Mich m 


1 

Daily 

Per 

Population    | 

Consumption 

Capita 

Gallons 

Gallons 

37,106 

('03) 

5,000,000 

125 

56,363 

('03) 

10,000.000 

168 

61.482 

('03) 

9.000.000 

145 

11,587 

COO) 

2,225,000 

125 

114,004 

('03) 

4,000.000 

36 

20,000 

('05) 

1.250.000 

63 

48,031 

('03) 

4.000.000 

84 

34.378 

('03) 

3.000,000 

90 

93,679 

('03) 

14.000.000 

139 

52,951 

('03) 

8,750,000 

135 

100,000 

('05) 

6,150.000 

67 

38,987 

('03) 

4,100,000 

111 

10,272 
75,000 

COO) 

('03) 

10.000.000 

134 

50,831 

('05) 

5,000,000 

100 

197,555 

('03 ) 

18,750,000 

94 

39,980 

('03 ) 

8,000.000 

200 

22,892 

COO) 

2,250,000 

100 

250,000 

('05) 

19,200.000 

77 

25,516 

('03) 

3,500,000 

200 

100,150 

('03) 

5,500,000 

52 

116,420 
72,350 

('03) 
('03 ) 

165 

5.500,000 

64 

215,722 

('03) 

18.000,000 

72 

44,158 

('03) 

18,000,000 

36 

60,845 

('03) 

3.500,000 

50 

38,274 

('03) 

4,200.000 

90 

214,112 

('03) 

18.500,000 

79 

313.025 

('03) 

27.000,000 

80 

113,669 

('03) 

12.000.000 

100 

20,818 

COO) 

2,900,000 

132 

55.318 

('03) 

6,300,000 

110 

66,000 

('05 ) 

7,000,000 

95 

300,625 

('03 ) 

14.000.000 

47 

20,628 

COO) 

2.000.000 

66 

83,275 

('03) 

13,500.006 

135 

114.627 

COO) 

20.000.000 

150 

29.919 

('03) 

2,500,000 

85 

113.217 

('03) 

10,500,000 

100 

02,348 

('03) 

4.500,000 

72 

10,112 

COO) 

1.000,000 

75% 

52,656 

('03) 

6.000.000 

110 

98,655 

('03) 

20,000,000 

200 

26,053 

('03) 

2,600.000 

103 

37,680 

('03 ) 

1.435,000 

38 

85.051 

('03) 

11,000,000 

124 

170,798 

('03) 

15,238,000 

87 

21,495 

COO) 

3,000.000 

94 

19.493 

COO) 

3,400,000 

17  • 

4,541 

COO) 

800.000 

160 

86.148 

('03 ) 

13,000,000 

129 

23,504 

('03) 

3,300,000 

89 

45,543 

('04) 

10,000,000 

200 

QUANTITY  OF  WATER  REQUIRED. 


49 


Table  V. —  (Continued.) 
Showing  Consumption  of  Water  in  105  American  Cities. 


City  and  State 


Sioux    City,    Iowa .  .  •. m 

Salt  Lake  City,  Utah m 

South  Bend,  Ind m 

St.    Joseph,    Mo p 

Somerville,   Mass m 

Springfield,   Mass m 

St.  Paul,  Minn m 

St.   Louis,   Mo m 

Springfield,    III m 

Syracuse,  N.  Y m 

San  Antonio,  Texas p 

Taunton,   Mass m 

Terre   Haute,    Ind p 

Toledo,   Ohio    m 

Utica,   N.   Y p 

Waterbury,   Conn m 

Vincennes,  Ind p 

Watertown,  N.  Y m 

Worcester,  Mass m 

Wilmington,  N.  C p 

Waltham,    Mass m 

Washington,   D.    C m 

Wilmington,    Del m 

York,  Pa p 

Yonkers,  N.  Y m 


Daily 

Per 

Population 

Consumption 

Capita 

Gallons 

Gallons 

33,111 

COO) 

1,290,000 

39 

57,138 

('03) 

15,000.000 

200 

40,327 

('03) 

4,000,000 

81 

110,479 

('03) 

6,000,000 

55 

68,090 

('03) 

6,000,000 

89 

74,916 

('05) 

9,700,000 

128 

172,038 

('03) 

9,000,000 

52 

612,279 

('03) 

75,000.000 

125 

36,211 

('03) 

4,470,000 

108 

114,443 

('03) 

12,000.000 

105 

58,016 

('03) 

10,000,000 

170 

32,713 

('03) 

1,750,000 

64 

54,008 

('05) 

4,200,000 

77 

145,901 

('03) 

11,000,000 

69 

60,097 

('03) 

4,000,000 

33 

56,521 

('05) 

6,000,000 

130 

10,249 

('00) 



21,696 

COO) 

4,000,000 

188 

130,207 

('05 ) 

10,000,000 

75 

20,976 

COO) 

700,000 

50 

23,481 

COO) 

2,000.000 

80 

300,000 

('05 ) 

65,000,000 

217 

84.000 

('05 ) 

8,000.000 

95 

36,438 

('03 ) 

2,850,000 

70 

62,000 

('05 ) 

6,500,000 

92 

"m" — Municipal,     "p" — Private  Company. 

This  excessive  consumption  is  brought  about  not  so  much  by 
legitimate  use  of  the  water  as  by  waste :  negligence  and  imperfections 
in  the  supply  apparatus,  allowing  the  water  to  run  in  the  winter  to 
prevent  freezing  of  pipes,  etc.  When  it  is  taken  into  consideration 
that  the  cost  of  pumping  water  averages  from  four  to  five  dollars  per 
million  gallons,  and  in  cities  which  purify  their  water-supply  the  cost 
is  from  two  to  three  dollars  more,  the  question  of  waste  assumes  a 
very  important  economic  phase.  In  several  of  the  larger  American 
cities  this  problem  has  been  satisfactorily  solved  by  the  introduction 
of  metres,  by  means  of  Avhich  the  water  consumed  in  each  household 
or  factory  is  measured  and  charges  regulated  according  to  the  amount 
of  water  consumed.  In  Wilmington,  Del.,  the  introduction  of  metres 
has  eliminated  waste  and  reduced  the  consumption  to  an  average  of 
100  gallons  per  capita.  This,  however,  includes  the  consumption  of 
water  by  manufactories.  In  one  of  the  strictly  residential  portions 
of  the  city  the  per  capita  consumption  averages  30  to  35  gallons  daily, 
the  latter  being  the  average  amount  of  water  required  by  a  middle- 
class  American  household.    One  of  the  objections  to  metres  is  that  the 


50  TEXT-BOOK  OF  HYGIENE. 

very  class  of  persons  whom  it  is  desired  to  induce  to  use  a  plentiful 
supply  of  water  would,  from  motives  of  economy,  use  less  than  is 
necessary  for  cleanliness  and  health.  This  objection,  however, -is 
purely  hypothetical.  Water  is  the  cheapest  commodity,  and  by  the 
elimination  of  waste  the  cost  could  be  still  further  reduced.  As  a 
matter  of  fact,  it  is  not  abundance  of  water  that  encourages  cleanli- 
ness. "You  can  lead  a  horse  to  the  water,  but  you  can't  make  him 
drink  it."  Habits  of  cleanliness  should  be  inculcated  in  ways  other 
than  by  allowing  a  wanton  waste  of  water. 

SOURCES    OF    DRINKING=WATER. 

All  water,  from  whatever  direct  source  obtained,  comes  origin- 
ally, by  precipitation,  from  the  atmosphere.  In  many  places  the 
rain-  or  snow-  water  is  the  only  source  of  supply.  This  is  usually 
collected  as  it  falls  upon  the  roofs  of  buildings  and  conveyed  by 
gutters  and  pipes  to  cisterns,  where  it  is  stored  until  needed. 

In  Venice,  the  rain  falling  upon  the  streets  and  courtyards  is 
also  collected  in  cisterns  after  filtering  through  sand.  The  cisterns 
used  for  the  storage  of  water  in  ISTew  Orleans  and  other  Southern 
cities  in  the  United  States,  where  the  temperature  rarely  falls  below 
the  freezing-point,  are  generally  constructed  of  wood  and  placed 
above-ground.  Farther  north,  where  it  is  necessary  to  protect  them 
against  the  action  of  frost,  they  are  placed  under-ground.  These 
under-ground  cisterns  are  usually  built  of  brick.  The  water  from 
cisterns  above-ground  becomes  very  much  heated  in  summer,  and 
necessitates  the  use  of  large  quantities  of  ice  to  make  it  palatable. 
The  water  from  the  under-ground  cisterns  is  pleasantly  cool  in  sum- 
mer, and  is  also  guarded  against  freezing  in  winter.  There  are, 
however,  very  serious  objections  to  storing  drinking-water  in  under- 
ground cisterns.  These  reservoirs  are  usually  placed  within  a  few 
feet  of  privies  and  cess-pools,  and,  as  neither  the  retaining  walls  of 
the  cisterns  nor  those  of  the  privies  are  water-tight,  it  often  happens 
that  the  drinking-water  becomes  strongly  impregnated  with  the  sol- 
uble portions  of  the  excrement,  or  the  products  of  its  decomposition, 
which  have  drained  into  the  cistern.  Personal  observations  in  Mem- 
phis in  1879,  as  well  as  the  careful  chemical  analyses  made  afterward 
by  Dr.  Chas.  Smart,  U.  S.  A.,*  have  convinced  the  author  that  the 
objections  to  all  under-ground  cisterns  built  of  brick,  stone,  or 
cement  are  insuperable  from  a  sanitary  point  of  view.     Dr.  Smart 


■Report  National  Board  of  Health,  1880,  pp.  437-441. 


SOURCES  OF  DUmKlNa-WATER.  51 

found  over  one-half  of  the  under-ground  cisterns  examined  by  him 
in  Memphis  and  other  cities  and  towns  to  be  leaky  and  presenting 
evidence  of  organic  pollution.  The  water  from  31  out  of  80  cisterns 
analyzed  showed  decided  contamination  by  sewage.  It  would  seem 
advisable  to  prohibit  all  under-ground  cisterns  for  the  storage  of 
drinking-water  unless  they  are  constructed  of  iron,  which  should 
be  protected  against  oxidation  by  a  thorough  coating  of  coal-tar. 
Where  any  other  system  of  collection  and  storage  is  available,  how- 
ever, the  under-ground  cistern  should  be  unreservedly  condemned. 

Eain-water  collected  in  the  country,  away  from  manufacturing 
districts,  is  usually  quite  pure  and  wholesome.  Its  taste  is,  however, 
flat  and  insipid,  owing  to  absence  of  carbon  dioxide  and  mineral  con- 
stituents. In  cities  rain-water  frequently  contains  such  a  large 
amount  of  organic  matter  and  other  impurities,  which  have  been 
washed  out  of  the  air  by  the  rain,  that  it  may  be  unfit  for  drinking. 
On  account  of  its  softness,  rain-water  is  very  desirable  for  washing 
and  other  domestic  purposes.  If  the  statement  made  in  the  last  chap- 
ter, concerning  the  presence  of  organisms  in  the  atmosphere,  is  remem- 
bered, then  it  will  be  evident  on  a  moment's  thought  that  such  organ- 
isms, when  contained  in  rain-water,  may  be  the  source  of  disease.  The 
putrefaction  which  so  readily  takes  place  in  rain-water  upon  standing 
a  few  days  is  caused  by  certain  of  the  organisms  carried  down  out 
of  the  lower  strata  of  the  air  by  the  descending  rain  or  snow. 

Precipitation  is  an  exceedingly  untrustworthy  source  of  water, 
and  should  never  be  depended  upon  when  other  sources  of  supply  are 
available.  Water  famines  are  frequent  wherever  people  are  com- 
pelled to  rely  upon  such  an  uncertain  source  of  supply  as  rain  or  snow. 

Elvers  and  smaller  streams  probably  supply  the  larger  number  of 
cities  and  towns  in  this  country  with  drinking-water.  When  care  is 
taken  to  prevent  the  pollution  of  the  stream  above  the  point  whence 
the  water  is  taken,  this  is  usually  of  fair  quality  for  domestic  pur- 
poses. When  the  river  can  be  tapped  near  its  source,  or  before  a 
large  number  of  manufacturing  establishments  can  empty  their  waste 
products  into  its  current,  or  before  it  receives  the  sewage  of  a  consid- 
erable number  of  inhabitants  living  on  its  banks,  the  water  can  gen- 
erally be  regarded  as  safe.  It  is  very  difficult,  however,  except  in  the 
less  settled  portions  of  the  country,  to  find  these  favorable  conditions. 

Among  the  minor  ol)iections  to  the  use  of  river-water  for  domes- 
tic purposes  are  the  liability  of  most  streams  to  become  turbid  in 
times  of  freshet,  and  the  discoloration  of  the  water  from  dissolved 
coloring-matters   if  tlie   stream   flows   through   a   marshy   or   peaty 


52       '  TEXT-BOOK  OF  HYGIENE. 

region.  These  objections  are,  however,  not  serious,  as  filtration  will 
readily  remove  the  suspended  matters.  The  coloring-matter  is  prob- 
ably harmless.  The  organic  matter  contained  in  the  water  of  some 
streams,  even  when  pollution  by  sewage  and  manufacturing  refuse  is 
absolutely  excluded,  may,  however,  be  the  cause  of  disease.  Dr. 
Smart  has  shown^  that  the  water  from  streams  in  Nebraska,  Wyom- 
ing, and  Utah  contained  organic  matter  varying  in  amount  from  .16 
to  .28  parts  per  million.''  He  thinks  the  so-called  "mountain  fever" 
of  the  Eocky  Moimtain  region  is  a  malarial  fever  caused  by  the  large 
amount  of  organic  matter  in  the  drinking-water. 

Dr.  G.  M.  Kober,  U.  S.  A.,  states  that  he  has  frequently  drunk 
water  from  mountain  streams  which  had  a  perceptible  taste  of  cattle- 
manure,  and  suggests  that  as  the  origin  of  the  ammonia  found  by 
Dr.  Smart  in  the  water  of  mountain  streams.  Dr.  Kober  also  regards 
the  "mountain  fever"  as  a  typhoid  fever  with  malarial  complications.' 

The  most  serious  objection  to  the  use  of  river-water  for  domestic 
purposes  is  the  emplo}mient  of  streams  as  carriers  of  refuse  from 
manufacturing  establishments,  or  of  the  sewage  of  cities  and  towns. 
In  Great  Britain  and  some  parts  of  the  continent  of  Europe,  owing 
to  the  density  of  population  and  the  variety  and  extent  of  manufac- 
turing industries,  many  of  the  streams  are  in  an  extremely  filthy 
condition.  In  this  country,  too,  especially  in  the  more  thickly  settled 
manufacturing  districts,  the  pollution  of  rivers  has  increased  to  a 
degree  to  seriously  jeopardize  the  health  of  the  people  who  are  com- 
pelled to  draw  their  water-supply  from  such  streams.  That  the  pres- 
ence of  such  excessive  contamination  renders  the  water  unsuitable  for 
domestic  purposes  must  appear  evident.  It  is  probable,  however,  that 
the  most  dangerous  of  the  polluting  matters  are  the  excreta  of  human 
beings,  especially  those  of  patients  suffering  from  certain  specific  dis- 
eases, such  as  typhoid  fever  or  cholera. 

Only  a  few  years  ago  it  was  a  generally-accepted  theory  that 
running  water,  though  polluted  by  sewage,  "purifies  itself"  after  fiow- 
ing  a  distance  of  twelve  miles,  and  the  comforting  and  reassuring  doc- 
trine is  still  held  by  many.  Recent  observations  point  to  the  con- 
clusion, however,  that  "no  river  is  long  enough  to  purify  itself."  A 
certain  proportion  of  the  sewage,  it  is  true,  undergoes  oxidation  in 
the  presence  of  light  and  air  and  minute  organisms,®  and  so  becomes 


^American  Journal  Med.  Sciences,  January,  1878,  p.  28  et  seq. 

•^  The  source  of  this  organic  matter  seems  to  be  the  melted  snow  which 
makes  up  a  large  portion  of  the  streams. 

'Report  of  California  State  Board  of  Health  for  1886,  pp.  48  and  177. 

'  Desinfection,  in  Eulenburg's  Realencyclopsedia  d.  ges.  Heilkunde,  vol.  iv, 
p.  68. 


SOURCES  OF  DEINKING-WATER.  53 

changed  into  other,  possibly  innocuous,  compounds.  But  at  present 
it  is  not  known  what  proportion  or  what  kind  of  organic  matter  does 
undergo  this  change.  Another  portion  of  the  impurities  is  deposited 
upon  the  bottom  and  sides  of  the  stream,  having  been  only  held  in 
suspension,  and  not  dissolved  in  the  water.  A  portion  probably  forms 
chemical  combinations  with  other  suspended  or  dissolved  matters,  and 
is  changed  into  compounds  which  may  be  volatile  and  pass  off  into 
the  air  or  form  insoluble  precipitates. 

The  remainder  is  rendered  less  perceptible  or  imperceptible  by 
dilution.  Every  stream  has  sources  of  inflowing  water — feeders — 
which  increase  its  volume,  and  thus  dilute  any  foreign  admixture. 

In  view  of  these  facts,  the  theory  of  the  self-purification  of 
streams,  as  formerly  held,  can  no  longer  be  regarded  as  true.  But  it 
is  unquestionably  true  that  running  water  does  regain  comparative 
purity  if  the  inflow  of  sewage  and  other  refuse  is  not  excessive.  It 
cannot  be  stated  with  confidence,  however,  when  a  stream,  once  pol- 
luted, becomes  fit  to  use  again. 

The  water  from  fresh-water  lakes  aiid  ponds  is  generar.y  to  be 
preferred  to  river-water  for  domestic  use.  It  is  less  liable  to  become 
turbid  from  time  to  time,  and,  except  in  the  case  of  small  ponds,  the 
inflow  of  sewage  is  not  likely  to  cause  fouling  of  the  water  to  any 
serious  extent.  When  the  supply  can  be  drawn  from  large  lakes,  as 
is  done  in  Chicago  and  other  cities  on  the  great  lakes  of  the  United 
States,  no  purer  or  better  source  can  be  desired.  In  these  cases  the 
point  whence  the  water  is  taken  should  be  far  enough  from  shore 
to  avoid  the  possibility  of  sewage  contamination.  When  the  water- 
supply  is  taken  from  small  ponds,  all  sewage  and  waste  products  from 
houses  and  factories  must  be  rigidly  excluded;  otherwise,  diseases 
attributable  to  the  polluted  water  are  likely  to  arise  among  those 
using  the  same. 

The  water  in  small  lakes  and  storage  reservoirs  sometimes  be- 
comes offensive  in  taste  and  odor.  The  water-supplies  of  several  of 
the  large  Eastern  cities  have  at  times  had  a  peculiar  odor  and  taste 
somewhat  resembling  cucumbers.  The  cause  of  this  odor  and  taste 
was  found  to  be  a  minute  fresh-water  sponge,  the  Spongilla  fluviatilis. 
A  still  more  offensive  odor,  tersely  described  as  the  "pig-pen  odor,"  is 
given  to  the  water  by  the  decay  of  certain  species  of  nostoc  and  other 
algffi.  It  is  not  known  that  either  these  vegetable  or  animal  micro- 
organisms,   if    present,    render    the    water    prejudicial    to    health. 

Ponds  are  often  used  as  sources  of  ice-supply.  It  was  formerly 
supposed  that  in  the  process  of  freezing,  solid  matters  in  the  water 


54  TEXT-BOOK  OF  HYGIENE. 

were  not  included  in  the  block  of  ice  when  congealation  occurred. 
Eecent  observations  have  shown  the  falsity  of  this  assumption.  In 
1875,  an  outbreak  of  acute  intestinal  disease  at  Eye  Beach,  ISTew 
Hampshire,  led  to  an  inquiry  by  Dr.  A.  H.  Nichols,  which  disclosed 
the  fact  that  the  ice  used  contained  a  large  percentage  of  organic 
matter.^  The  use  of  ice  from  a  different  source  was  followed  by  an 
almost  immediate  disappearance  of  the  disease.  Upon  further  inves- 
tigation it  was  discovered  that  the  impure  ice  had  been  gathered 
from  a  small,  stagnant  pond  into  which  a  small  brook  carried  large 
quantities  of  saw-dust  from  several  saw-mills.  The  water  of  the  pond 
was  loaded  with  organic  matter,  and  in  summer  the  gases  of  decay 
arising  from  it  were  very  offensive.  Chemical  examination  showed 
that  the  ice  from  this  pond  contained  nearly  6  quarts  of  organic  matter 
in  100,000,  while  in  pure  ice  the  organic  matter  amounted  to  only  .3 
part  in  100,000.  A  similar  investigation  into  the  character  of  the  ice 
furnished  to  the  residents  of  Newport,  E.  I.,  was  made  under  the 
auspices  of  the  Sanitary  Protection  Association  of  that  city.  The  ice, 
which  was  cut  from  ponds  in  the  immediate  neighborhood  of  the  city, 
was  found  to  contain  an  excessive  proportion  of  organic  matter. 
Large  quantities  of  sewage  and  other  impurities  were  discharged  into 
these  ponds. 

Experiments  made  at  various  times  show  that  the  purification 
of  water  by  freezing  is  in  no  sense  absolute.  A  considerable  num- 
ber of  the  bacteria,  infusoria,  and  other  organisms  remain  in  the  ice 
and  retain  their  vitality,  so  that  when  thawed  they  rapidly  multiply. 
In  the  ordinary  process  of  freezing  the  upper  portion  is  the  purest, 
but  if  snow  or  rain  fall  upon  the  ice  and  freeze,  this  upper  layer 
will  be  found  much  more  impure  than  the  lower.  Eational  conclu- 
sions from  these  experiments  are,  that  ice  should  not  be  gathered 
from  an  impure  source,  and  that  an  early  harvest  of  the  ice  should  be 
encouraged. 

Prudden  has  sho^^^l  that  typhoid  bacilli  contained  in  water  are 
not  entirely  destroyed  by  freezing,  even  after  remaining  in  this  con- 
dition for  103  days. 

Springs  and  wells  supply  the  water  for  most  persons  not  aggre- 
gated in  large  communities,  as  cities  and  towns.  Even  in  the  latter 
no  inconsiderable  quantity  of  the  water  used  for  drinking  and  domes- 
tic purposes  is  derived  from  wells.  Spring-water  usually  comes  from 
a  source  at  a  considerable  depth  below  the  surface;   that  is  to  say,  the 


'Report  Massachusetts  State  Board  of  Health,  1876,  p.  467. 


SOURCES  OF  DRINKING-WATER. 


55 


water  has  percolated  through  thick  strata  of  soil  before  re-appearing 
at  the  surface.  In  its  passage  through  the  soil  it  has  lost  most  of 
its  organic  matter,  and  perhaps  taken  up  mineral  and  gaseous  con- 
stituents in  larger  quantities.  It  may  be  so  strongly  impregnated 
with  the  latter  as  to  vitiate  it  for  ordinary  use  and  to  render  it  val- 
uable as  a  medicine.  Ordinarily,  however,  spring-water  is  clear,  cool, 
and  sparkling,  with  a  refreshing  taste  and  uniform  temperature,  and 
is  in  all  respects  an  agreeable  and  wholesome  beverage. 

Springs  vary  greatly  in  character.  They  may  be  cold,  hot,  or 
thermal,  and  boiling  or  geysers;  they  may  be  either  superficial  or 
deep,  and  the  water  may  be  either  pure  or  polluted,  depending  on 


Fig.   3.— Showing  Formation  of  Spring.     E,  Earth.     R,  Rock.     W8, 
Water-bearing  Stratum.     IB,  Impervious  Stratum.    *S',  Spring. 

source  or  location.  The  chemical  constituents  of  spring-waters  in 
this  country  vary  from  waters  containing  but  a  few  grains  of  mineral 
substances  to  the  gallon  to  waters  so  saturated  with  mineral  matter 
as  to  be  classed  as  medicinal. 

The  various  mineral  waters  in  this  country  are  classified  by  Hay- 
wood and  Smith^°  as  follows : — 


Group. 


Thermal 
Nonthermal 


Class. 


I.  Alkaline 


II. 


Alkaline- 
saline 


TIL  Saline 


IV.  Acid 


Table  VI. 

Subclass 

{Carbonated  or 
bicarbonated 
Borated 
Silicated 
(Sulphated 
Muriated 
Nitrated 
r  Sulphated 
I    Muriated 
I  Nitrated 
<  Sulphated 
/   Muriated 


Sodic 

1  Lithic 

Potassic 
'  Calcic 

Magnesic 

Ferruginous 

Alumnic 

Arsenic 
kBromic 
llodic 
/Silicous 

Boric 


I  Nongaseous 
Carbondioxated 
Sulphuretted 
Azotized 
Carburetted 

I  Oxygenated 


'"Bureau  of  Chemistry,  Bui.,  91, 


56  TEXT-BOOK  OF  HYGIENE. 

Under  this  classification  the  mineral  waters  on  the  market  may 
be  arranged  as  follows : — 

Alkaline  Bicarhonated  Sodic. — Augusta  White  lithia  water.  Gey- 
ser Jefi^ress  lithia  water.  JManitou  water.  Powhatan  water.  Thomp- 
son's bromin  and  arsenic  water. 

Alkaline  Bicarhonated  Magnesic. — Osceola  water. 

Alkaline  Bicarhonated  Calcic. — Allouez  water.  Augusta  White 
lithia  water.  Bear  lithia  water.  Crocket  arsenic  lithia  water.  Gol- 
indo  lithia  water.  Great  Bear  water.  Jeffress  lithia  water.  London- 
derry lithia  water.  Manitou  water.  Mardela  water.  Massanetta 
water.  Missisquoi.  Osceola  water.  Otterburn  water.  Poland  water. 
Powhatan  M^ater.  Eubino  Healing  Springs  water.  Sublett  lithia 
water.    Yitan  water. 

Alkaline  Bicarhonated  Ferruginous. — Mardela  water. 

Alkaline-saline  Muriated  Sodic. — Carlsbad  water.  Champion 
water.  Chief  water.  Congress  water.  Hathorn  water.  High  Eock 
water.  Lincoln  water.  Magnetic  water.  Peerless  water.  Gitche 
Crystal  Spring  water.  Seltzer  water.  Sheboygan  water.  Vichy 
water.    White  Eock  lithia  water. 

Alkaline-saline  Muriated  Potassic. — Gitche  Crystal  Spring  water. 

Alkaline-saline  Muriated  Calcic. — Carlsbad  water.  Champion 
water.  Chief  water.  High  Eock  water.  Lincoln  water.  Magnetic 
water.  Peerless  water.  Seltzer  water.  White  Eock  lithia  water. 
Sheboygan  water. 

Saline  Sulphated  Sodic. — Pluto  concentrated  water. 

Saline  SulpJiated  Magnesic. — Veronica  water. 

Saline  Sulphated  Calcic. — Berry  Hill  d^^spepsia  water.  Bedford 
mineral  water.  Buffalo  lithia  water.  Geneva  lithia  water.  Tate 
epsom  water. 

Saline  Muriated  Sodic. — Arondack  water.  Blue  Lick  water. 
Cherrydale  water.  Deep  Eock  water.  Mount  Clemens  water.  Star 
water.    A^ictoria  Avater.     Webster  Springs  salt  sulphur  water. 

Saline  Muriated  Calcic. — Cherrydale  water. 

Add  Sulphated  Aluminic. — Eockbridge  alum  water.  Walla- 
whatoola  water. 

Eegarding  the  effect  of  mineral  waters  on  the  human  organism 
both  in  health  and  disease,  Haywood  and  Smith^^  present  the  follow- 
ing summary: — 

Carhonated  or  Bicarhonated  Alkaline  Waters. — Stimulate  the  se- 
cretions of  the  digestive  tract,  neutralize  hyperacidity  of  the  stomach, 

^Loc  cit. 


SOURCES  OF  DRIXKIXG-WATER.  57 

increase  metabolism,  dissolve  uric  acid  and  uric  acid  deposits,  increase 
the  flow  of  urine,  and  correct  acidity  of  the  latter.  They  are,  there- 
fore, of  value  in  catarrhal  conditions  of  the  mucous  membranes,  rheu- 
matism, gout,  diabetes,  etc. 

8odic  Carbonated  and  Bicarhonated  AlJcaline  Waters. — Increase 
metabolism,  dissolve  uric  acid,  and  allay  irritation  of  the  mucous 
membrane  of  the  urinary  tract.  They  are  useful  in  acid  dyspepsia, 
rheumatism,  gout,  and  diabetes. 

Potassic  Carbonated  and  Bicarhonated  AlJcaline  Waters. — Have 
very  much  the  same  action  as  the  sodic  carbonated.  Their  chief  use  is 
in  the  treatment  of  calculi. 

Lithic  Carbonated  and  Bicarbonated  All-aline  Waters. — These  are 
active  diuretics  and  form  solul^le  urates.  They  are  used  in  the  treat- 
ment of  rheumatism,  rheumatic  tendencies,  and  gout.  In  cases  of 
gravel  and  calculi  they  are  a^so  valuable  disintegrating  agents. 

Magnesic  Carbonated  and  Bicarbonated  All-aline  Waters. — Act  as 
mild  laxatives,  and  are  perhaps  the  best  of  all  the  alkaline  waters  in 
correcting  an  acid  condition  of  the  stomach  and  curing  sick  headache 
caused  by  constipation.  They  favor  the  solution  of  uric  acid,  are  val- 
uable agents  in  breaking  up  deposits  in  the  bladder,  and  are  much  used 
in  catarrhal  conditions  of  the  mucous  membrane  or  the  urinary  organs. 

Calcic  Carbonated  and  Bicarbonated  Alhaline  Waters. — This 
class  of  waters  produces  constipation  and  decreases  the  secretions. 
Very  obstinate  cases  of  chronic  diarrhea  have  been  cured  by  a  sojourn 
at  a  spring  rich  in  calcium  bicarbonate.  Uric  acid  gravel  and  calculi 
are  also  disintegrated  and  eliminated  by  the  free  use  of  these  waters. 

Ferruginous  Bicarbonated  All-aline  Waters. — Increase  the  amount 
of  hemoglobin  and  in  connection  therewith  increase  the  temperature, 
pulse,  and  weight.  They  also  increase  the  appetite  and  reduce  intes- 
tinal activity.  They  give  excellent  results  as  a  tonic,  and  find  their 
principal  application  in  anemia  and  general  debility.  Prolonged  use 
results  in  constipation  and  derangement  of  the  digestion. 

B orated  Alhaline  Waters. — They  act  as  antacids.  They  promote 
the  menstrual  flow  and  may  be  used  in  catamenial  irregularities. 

Muriated  AlMUne-saline  Waters. — They  increase  the  flow  of 
urine  and  the  excretion  of  uric  acid.  Are  especially  valuable  in  the 
treatment  of  catarrhal  conditions  of  the  mucous  membrane  of  the 
stomach,  intestines,  biliary  passages,  and  urinary  tract. 

Sulphated  All-aline-saline  Waters. — They  act  as  diuretics.  In 
large  quantities  they  act  as  purgatives  by  increasing  the  peristaltic 
movement  and  liquefying  the  intestinal  contents.     Valuable  in  the 


58  TEXT-BOOK  OF  HYGIENE. 

treatment  of  catarrhal  conditions  of  the  mucous  membrane  and  in 
obesity. 

Muriated  Saline  Waters. — Stimulate  the  secretion  of  the  stom- 
ach, increase  digestion,  favor  a  better  absorption  of  foods,  and  act  as 
diuretics. 

Sodic  Muriated  Saline  Waters. — Increase  the  flow  of  gastric 
juice,  improve  the  appetite,  increase  the  flow  of  urine  and  excretion 
of  urea.    Also  prevent  putrefactive  changes  in  the  intestines. 

Potassic  Muriated  Saline  Waters. — Action  very  much  like  that 
of  sodium  salt. 

Lithic  Muriated  Saline  Waters. — Same  as  above,  with  an  intensi- 
fied diuretic  action  due  to  the  lithium. 

Calcic  Muriated  Saline  Waters. — Act  as  a  tonic,  increase  the  flow 
of  urine,  sweat  and  bile,  and  are  used  in  scrofula  and  eczema. 

Sulphated  Saline  Waters. — These  waters  are  laxative  or  purga- 
tive, according  to  the  amount  taken.  Are  indicated  where  long-con- 
tinued intestinal  stimulation  is  desired  without  stimulation  of  the 
vascular  system. 

Sodic  and  Magnesic  Sidpliated  Saline  Waters. — Act  as  laxatives 
in  small,  and  purgatives  in  large,  doses.  Increase  flow  of  intestinal 
fluids  and  urine,  also  excretion  of  urea.  Are  of  great  service  in  elim- 
inating syphilitic,  scrofulous,  and  malarial  poisons  from  the  system, 
in  throwing  off  mercury  and  other  poisons.  Useful  in  the  treatment 
of  obesity,  derangement  of  the  liver,  and  Bright's  disease. 

Potassic  Sulphated  Saline  Waters. — Same  effect  as  above. 

Calcic  Sulphated  Saline  Waters. — Have  no  well-known  action. 

Ferruginous  Sulphated  Saline  Waters  and  Ahuninic  Sidphated 
Saline  Waters. — Iron  and  aluminum  usually  occur  together  when 
either  is  present  as  a  predominating  constituent  in  sulphated  saline 
waters.  These  are  practically  always  acid  and  their  action  is  best 
considered  under  the  sulphated  acid  group. 

Nitrated  Saline  Waters. — Only  one  spring  of  this  kind  found. 
Action  has  not  been  determined. 

Acid  Waters. — Principally  composed  of  the  ferruginous-aluminic 
sulphated  classes,  although  there  are  a  few  acid  springs  which  contain 
comparatively  little  iron  and  aluminum,  but  quite  large  amounts  of 
calcium,  sodium,  or  magnesium.  These  waters  are  used  in  relaxed 
conditions  of  the  mucous  membranes,  especially  in  diarrhea  and  dysen- 
tery. They  are  also  used  in  the  treatment  of  exhausting  night-sweats 
and  impoverished  condition  of  the  body  brought  about  by  intemper- 
ance or  specific  diseases.     Locally,  they  are  used  in  the  treatment 


SOURCES  OF  DRINKING-WATER.  59 

of  inflamed  or  relaxed  conditions  of  the  mucous  membrane  such  as 
are  found  in  conjunctivitis,  chronic  vaginitis,  etc.  Have  the  usual 
effect  of  all  iron  waters,  but  when  desired  as  a  tonic  it  is  best  to  give 
the  ferruginous  carbonated  water,  as  the  latter  is  more  readily  ab- 
sorbed and  assimilated. 

Iodic  and  Bromic  Waters. — Act  as  alteratives.  Stimulate  the 
lymphatic  system  to  greater  activity  and  promote  absorption  in  all 
tissues.  Indicated  in  the  treatment  of  scrofula,  syphilis,  goitre, 
chronic  exudations,  etc.  Also  favor  the  elimination  of  mercury  and 
other  metallic  poisons.    The  bromic  waters  also  act  as  sedatives. 

Arsenic  Waters. — Act  as  alteratives,  increase  the  appetite  and 
digestion,  and  improve  the  general  nutrition  of  the  body  by  increas- 
ing the  secretions  of  the  gastro-intestinal  mucous  membrane  and  at 
the  same  time  checking  katabolism.  Especially  valuable  in  the  treat- 
ment of  anemia  and  a  number  of  skin  diseases.  Also  indicated  in 
chronic  malaria,  neuralgia  of  anemic  origin,  scrofula,  etc. 

Silicious  Waters. — Precise  action  unknown.  Have  been  said  to 
be  useful  in  cancer  and  to  have  caused  the  disappearance  of  albumin 
and  sugar  from  the  urine. 

Azotized  and  Oxygenated  Wateis. — On  account  of  slight  solu- 
bility neither  nitrogen  nor  oxygen  occurs  in  waters  in  very  large 
quantities.     They  possess  no  medicinal  value. 

Carhondioxated  Waters. — Increase  the  flow  of  saliva  and  intes- 
tinal fluids,  also  increase  the  peristaltic  movement  of  the  stomach 
and  thereby  improve  digestion.  Also  tend  to  increase  the  flow  of 
urine.     Obstinate  cases  of  nausea  are  often  relieved  by  these  waters. 

Carhuretted  Waters. — Sometimes  occur  in  coal  and  natural  gas 
regions.  Are  not  known  to  have  any  medicinal  value,  but  are  usually 
considered  unfit  for  drinking  purposes. 

Sulphuretted  Waters. — Increase  the  action  of  the  skin,  intestines, 
and  kidneys.  Also  possess  a  decided  alterative  effect.  Have  been 
used  in  the  treatment  of  syphilis,  chronic  metallic  poisoning,  rheu- 
matism, and  'gout.  They  have  also  given  excellent  results  in  many 
skin  diseases,  hyperhemia  of  the  liver,  and  in  catarrhal  conditions  of 
the  pharjTix,  lar^mx,  and  bronchi. 

The  great  demand  for  spring-waters,  especially  mineral  waters, 
has  called  forth  a  supply  of  all  kinds  of  spring-waters,  good,  bad,  and 
iufliffercnt.  In  many  cases  the  claims  made  by  the  promotors  are  so 
extravagant  as  to  class  the  water  among  the  rankest  of  patent  medi- 
cines. The  United  States  Bureau  of  Chemistry,  therefore,  has  done 
a  most  valuable  service  to  the  people  and  the  medical  profession  by 


60 


TEXT-BOOK  OF  HYGIENE. 


analj'zing  the  more  popular  mineral  waters.  The  following  table 
shows  the  results  of  some  of  these  analyses,  compiled  from  Bulletin 
No.  91:— 

Table  VII. 

Showing  Analyses  of  Some  of  the  3Iore  Popular  Mineral   Waters. 


=i 

a 
o 

a 

a 

.1 

1 

2 

S 

■a 
_o 

3 

-S 

o 

2 

J3 

'3 

o 

a 
a 
< 

< 

^ 

2 

3 

o 

.d 

tH 

'0 
o 

M 

a 

3 

2 
'S 

c 

a 

3 

a 

3 

a 

s 

3 
O 

.3 

a 

o 

a 

_3 

3 

a 

a, 

3 

a 

CD 

o 

o 

X 

a 

is 

c3 

3 

cs 

•5 

U 

a 

O 

T3 

c 

-a 

U4 

■< 

'A 

2 

o 

< 

M 

P-, 

IB 

Ph 

CO 

Part-^  per  Million. 


,008 

.051 

1.33 

.001 

.45 

0.24 

(a) 

4.6 

46 

5.3 

(Calcic  Bicarb.  Alkaline) 

08 

3.05 

392.8 

0 

.25 

.24 

169.5 

3,170 

(a) 

802.7 

14  151  4 

(Magoesic  Sulphated  Sal.) 

Bedford  Mineral  Water  .  . 
(Calcic  Suiphated  Saline) 

,014 

.008 

.05 

Tr. 

.85 

.015 

Tr. 

9.3 

9.2 

29  0 

686.1 

Geneva  Lithia  Water   .   .   . 
(Calcic  Suiphated  Saline) 

.015 

.015 

.10 

Tr. 

.55 

.048 

.6 

7.6 

330.4 

Tr. 

2.8 

575  3 

Buffalo  Lithia  Water 
(Calcic  Suiphated  Saline) 

.035 

0 

.50 

Tr. 

.60 

.114 

Tr. 

76 

12 

77.7 

31.7 

Vitau  Table  Water 

(Cal  ic  Bicarb.  Alk.) 

0 

.05 

.20 

0 

.45 

(a) 

10  5 

Tr. 

14.9 

.01 

.04 

20 

Tr. 

.30 

03 

Tr. 

32 

17  5 

11  0 

(Calcic  Bicarb.  Alk.) 

Londonderry  Lithia  Water 
(Calcic  Bicarb.  Alk.) 

.015 

.075 

.66 

Tr. 

.90 

.048 

Tr. 

5.5 

.5 

11.2 

White  Rock  Lithia  Water  . 

.04 

.09 

1  0 

.005 

.50 

.125 

76.4 

5.7 

573.6 

49.6 

Bear  Lithia  Water     .  .  . 
(Calcic  Bicarb.  Alk.) 

.02 

.04 

.2 

Tr, 

.25 

.063 

Tr. 

3  1 

12 

Tr. 

4.3 

Massanetta  Water          .  .  . 
(Calcic  Bicarb,  Alk.) 

.175 

.054 

'    .5 

.001 

.45 

.549 

(a) 

2.9 

0 

Otterburn  Lithia  Water  . 
(Calcic  Bicarb  Alk. ) 

.065 

.027 

Tr. 

001 

.70 

207 

.28 

.3.6 

43 

41 

Tr.,  Trace;  (a).  Heavy  Trace. 


SOURCES  OF  DRINKING-WATER.  61 

The  above  table  shows  how  several  of  the  high-priced  and  much- 
vaunted  lithia  waters  are  such  only  in  name,  while  some  of  the  sup- 
posedly pure  spring-waters  are  no  better  than  water  from. an  average 
farm-spring. 

The  character  of  well-water  is  often  justly  open  to  grave  suspicion. 
Being  derived  from  those  strata  of  the  soil  which  are  most  likely  to 
be  contaminated  by  the  products  of  animal  and  vegetable  decompo- 
sitions, the  unwholesomeness  of  the  water  is  inversely  proportional 
to  the  degree  of  saturation  of  the  soil  with  the  products  of  decay.  It 
has  been  found  by  experiment  that,  when  organic  matter  largely 
diluted  with  water  is  allowed  to  percolate  through  soil,  it  undergoes 
a  gradual  decomposition  in  the  presence  of  certain  minute  organisms, 
nitrates  and  nitrites  being  formed  at  the  expense  of  the  ammonia 
and  other  organic  combinations.  If,  however,  the  soil  is  saturated 
with  organic  matter  in  excess,  and  in  a  state  of  concentration,  putre- 
faction takes  place,  and  the  conversion  of  the  organic  matter  into 
nitrates  and  nitrites  is  retarded. 

Deep  or  Artesian  Wells. — The  name  artesian  is  derived  from  the 
province  of  Artois,  France,  where  these  wells  were  simk  centuries  ago. 
They  are  formed  when  a  boring  taps  a  water-bearing  stratum  con- 
fined between  two  impervious  geological  formations.  This  water- 
bearing stratum  forms  a  subterranean  reservoir  which  is  fed  by  the 
percolation  of  the  surface  at  some  point  where  the  upper  impervious 
stratum  is  either  fissured  or  absent.  This  is  known  as  the  catchment 
area.  This  area  may  be  near  or  far  from  the  point  where  the  well  is 
sunk  and  it  may  be  subject  to  pollution,  and  there  is,  therefore,  no 
absolute  assurance  that  because  a  well  is  deep  the  water  is  always 
pure.  Sedgwick  and  Prescot  found  the  following  numbers  of  bac- 
teria in  a  series  of  deep  wells  in  Massachusetts : — ■ 


Table  VIII. 

Depth  of  Well 

Number  of  Bacteria  Fer 

in  feet. 

Cubic  Centimetre. 

100 

• 

30 

193 

269-254 

213 

101-106 

254 

150-135 

377 

48-54 

454 

205-214 

Pfuhl,  a  well-known  German  authority,  cites  an  instance  of  pol- 
lution passing  through  180  feet  of  gravel.     The  chief  objection  to 


62  TEXT-BOOK  OF  HYGIENE. 

artesian  wells  is  their  high  contents  in  mineral  substances,  which  im- 
part to  the  water  a  permanent  hardness.  In  some  regions  the  amount 
of  iron  is  so  great  as  to  act  destructively  on  tlie  pipes.  Thus,  in  the 
town  of  Gloucester,  N".  J.,  the  artesian  wells  which  supplied  that  town 
with  water  had  to  be  abandoned,  owing  to  the  excess  of  iron  in  the 
water. 

The  following  analyses  of  the  water  from  the  four  artesian  wells 
in  Gloucester  were  made  by  Messrs.  Hamlin  and  Morrison: — 

Table  IX. 

Parts  Per  Million. 

Well  Number  12  3  4 

Calcium  carbonate   45       21  00  00 

Magnesium  carbonate  23       19  17  12 

Calcium  sulphate    51       49  65  73 

Sodium  chlorid 9       11  18  16 

Iron  oxid  and  aluminum 14       11  22  62 

Matter  insoluble  in  acid 00       00  32  30 

Volatile  and  inorganic  matter 28         6  76  30 

Nitrates 00       00  00  00 

Nitrites    00       00  00  00 

Iron 9         7  9  14 

Total  solids    172     117     220     223 

The  quantity  of  water  to  be  obtained  from  artesian  wells  is  very 
uncertain,  depending,  as  it  does,  on  the  extent  of  the  catchment  area, 
the  rainfall,  and  the  number  of  taps  along  the  subterranean  water- 
course. In  some  localities  it  may  be  impossible  to  obtain  an  artesian 
supply,  and  again  the  supply  may  be  large  at  first  and  gradually 
diminish. 

Drinking-water  is  sometimes  procured  by  melting  snow  or  ice. 
It  is  not  probable  that  water  derived  from  these  sources  is  unwhole- 
some, although  there  is  strong  popular  prejudice  against  it.  Ice  and 
snow  may,  however,  contain  large  amounts  of  impurities,  as  already 
referred  to,  and  be  for  this  reason  unfit  for  use. 

The  following  qualities  are  desirable  in  water  for  drinking  and 
domestic  purposes : — 

1.  The  water  should  be  colorless,  transparent,  sufficiently  aerated, 
of  uniform  temperature  throughout  the  year,  and  without  odor  or  de- 
cided taste. 

2.  The  mineral  constituents  (magnesium  and  lime  salts)  should 


IMPURITIES  IN  WATER.  63 

not  be  present  in  greater  proportion  than  4  or  6  parts  per  100,000. 
More  than  this  gives  to  water  that  quality  known  as  "hardness." 

3.  There  should  be  but  little  organic  matter  present,  and  no  liv- 
ing or  dead  animal  or  vegetable  organisms. 

4.  The  water  should  be  almost  free  from  ammonia  and  nitrous 
acid,  and  should  contain  but  very  small  quantities  of  nitrates,  chlor- 
ides, and  sulphates. 

5.  It  should  contain  less  than  one  milligramme  of  lead  per  litre. 
A  larger  proportion  than  this  is  likely  to  be  followed  by  lead  poisoning. 

6.  It  should  contain  no  pathogenic  bacteria  and  but  few  water 
bacteria. 

IMPURITIES   IN  WATER. 

The  transparency  and  the  color  of  water  are  affected  by  the 
presence  of  suspended  or  dissolved  mineral  or  organic  matters.  If, 
after  standing  for  a  time,  the  water  deposits  a  sediment,  this  is  de- 
pendent upon  insoluble  matters.  If  the  sediment  turns  black  when 
heated  in  a  porcelain  capsule  over  an  alcohol  or  gas  flame  it  contains 
organic  matter.  If  the  sediment  or  residue  effervesces  upon  the  ad- 
dition of  hydrochloric  acid  the  presence  of  carbonates  is  indicated. 
Water  may  be  colored  by  metallic  salts  or  by  vegetable  matter.  It 
may  also  contain  large  quantities  of  mineral  or  organic  matter,  or 
even  living  organisms,  without  especially  diminishing  its  transparency. 
For  example,  the  ova  of  tape-worms  may  exist  in  water  in  considerable 
numbers  and  yet  remain  perfectly  invisible  except  under  the  micro- 
scope. 

The  presence  of  sulphur  compounds,  or  of  various  vegetable  and 
animal  organisms  (sponges,  algae,  etc.),  may  give  to  water  an  un- 
pleasant odor  and  taste.  In  the  oil  regions  of  this  country  most  of 
the  drinking-water  is  contaminated  with  petroleum,  which  is  very 
disagreeable  to  one  unaccustomed  to  it.  It  is  not  probable  that  the 
small  quantities  of  the  oil  imbibed  with  the  water  have  any  deleterious 
influence  upon  the  organism. 

Many  works  on  hygiene  fix  a  limit  to  the  amount  of  solid  matter 
allowable  in  drinking-water.  The  International  Congress  of  Hygiene, 
at  Brussels,  fixed  the  limit  at  50  parts  in  100,000.  It  is  impossible, 
however,  to  say  of  any  particular  specimen  of  water  that  its  content 
of  solid  matter,  whether  organic  or  mineral,  will  be  prejudicial  to 
health,  without  trial.  At  the  same  time  it  is  prudent  to  reject  all 
waters  containing  a  considerable  proportion  of  solid  organic  matter, 


64  TEXT-BOOK  OF  HYGIENE. 

as  determined  by  the  degree  of  blackening  on  heating  the  sediment  or 
residue  after  evaporation,  or  by  determination  of  nitrogen. 

The  hardness  of  water  is  due  to  the  presence  of  earthy  carbonates, 
or  sulphates,  or  both.  If  the  hardness  is  due  to  carbonates  it  is  dissi- 
pated by  heat,  as  in  boiling  the  water;  the  carbon  dioxide  is  driven 
off,  and  the  base  (calcium  or  magnesium  oxide)  is  precipitated  upon 
the  bottom  and  sides  of  the  vessel.  This  is  termed  "temporary  hard- 
ness." The  hardness  due  to  the  presence  of  earthy  sulphates  is  not 
removed  upon  heating  the  water,  and  is  termed  the  "permanent  hard- 
ness." The  hardness  depending  upon  both  the  carbonates  and  sul- 
phates is  called  the  "total  hardness." 

The  proportion  of  the  above-mentioned  earthy  salts  present  in 
a  given  specimen  of  water  is  determined  by  what  is  called  the  soap 
test. '  This  test  depends  upon  the  property  which  lime  and  magnesia 
salts  possess  of  decomposing  soap  (oleate  and  stearate  of  soda).  The 
quantity  of  a  solution  of  soap  of  a  definite  composition  decomposed 
by  a  quantity  of  hard  water  indicates  the  amount  of  the  salts  present. 

DISEASES    DUE   TO   IMPURE    DRINKING=WATER. 

Hard  water  is  popularly  believed  to  be  the  cause  of  calculous  dis- 
eases and  of  goitre  and  cretinism,  but  no  reliable  observations  are  on 
record  showing  that  the  belief  is  founded  upon  fact.  At  the  same 
time  it  is  undoubtedly  true  that  calcareous  waters  produce  gastric  and 
intestinal  derangements  in  those  unaccustomed  to  their  use. 

Large  amounts  of  suspended  mineral  matter  are  frequently  pres- 
ent in  river-water,  and  may  give  rise  to  derangements  of  the  digestive 
organs.  If  there  is  carbonate  of  lime  present,  the  water  can  be  easily 
clarified  by  the  addition  of  a  small  quantity  of  alum.  Sulphate  of 
lime  and  a  bulky  precipitate  of  hydrate  of  alumina  are  formed,  whicli 
carry  the  suspended  matters  to  the  bottom.  About  10  centigrammes 
of  crystallized  alum  are  sufficient  to  clarify  a  litre  of  water.  This 
amount  of  alum  is  too  small  to  affect  the  taste  of  the  water  percept- 
ibly. This  method  is  frequently  used  to  clarify  and  render  fit  for  use 
the  water  of  the  ]\Iississippi  Eiver,   which  is  usually  very  muddy. 

Lately,  the  city  of  St.  Louis,  which  derives  its  water-supply  from 
the  Mississippi  Eiver,  has  been  using  ferrous  sulphate  and  lime  as  a 
coagulant,  instead  of  alum.  The  action  of  either  of  these  coagulants 
is  to  conglomerate  the  fine  particles  of  clay  and  thus  facilitate  their 
sedimentation.  At  the  same  time  these  coagulated  solid  particles 
carry  with  them  the  bacteria,  and  a  purification  of  90  to  98  per  cent, 
results. 


DISEASES  DUE  TO  IMPURE  DRINKING-WATER.  65 

Although  the  opinion  is  widespread  that  water  containing  much 
mineral  matter,  either  in  solution  or  in  suspension,  is  deleterious  to 
health,  there  is  very  little  evidence  absoliitely  trustworthy  upon  this 
point. 

The  presence  of  large  quantities  of  organic  matter  in  water, 
whether  these  matters  be  of  animal  or  vegetable  origin,  must  always 
be  looked  upon  with  suspicion.  The  observation  was  made  by  Hippoc- 
rates twenty-three  centuries  ago,  that  persons  using  water  from 
marshes,  i.e.,  water  containing  vegetable  matter,  suffer  from  enlarged 
spleens.  Many  physicians,  both  of  ancient  and  modern  times,  seem 
to  have  held  this  opinion,  but  the  first  positive  observation  in  medical 
literature  is  the  now  classical  one  of  the  ship  Argo,  reported  by 
Boudin.^^  In  1834  the  transport  Argo,  in  company  with  two  other 
vessels,  carried  800  soldiers  from  Bona,  in  Algiers,  to  Marseilles.  The 
troops  were  all  in  good  health  when  they  left  Algiers.  All  three  of 
the  vessels  arrived  in  Marseilles  on  the  same  day.  In  two  of  them 
there  were  680  men,  not  one  of  whom  was  sick.  Out  of  the  remain- 
ing 120  men  who  were  on  the  third  vessel,  the  Argo,  13  died  during 
the  passage,  and  98  of  the  107  survivors  suffered  from  paludal  fevers 
of  all  forms.  None  of  the  crew  of  the  Argo  were  sick,  however.  The 
two  vessels  exempt  from  sickness,  and  the  crew  of  the  Argo,  had  been 
supplied  with  pure  water,  while  the  soldiers  on  the  latter  vessel  had 
been  furnished  with  water  from  a  marsh.  This  water  was  sa'id  to 
have  a  disagreeable  odor  and  taste.  The  testimony  of  a  large  number 
of  East  India  physicians  is  also  quoted  by  Parkes  in  support  of  the 
view  that  malarial  fevers  are  often  caused  by  impure  drinking- 
water.  The  observations  of  Dr.  Charles  Smart,  upon  the  production 
of  '^mountain  fever"  of  the  Western  territories,  have  already  been 
referred  to.  It  is  more  than  likely,  however,  that  the  cases  on  the 
Argo  were  typhoid  fever. 

The  causation  of  typhoid  fever  and  cholera  by  impure  drinking- 
water  will  be  presently  referred  to. 

There  can  be  very  little  doubt  that  diarrhea  and  dysentery  are 
frequently  caused  by  water  which  has  been  contaminated  with  de- 
caying organic  matter.  The  evidence  in  favor  of  this  amounts  prac- 
tically to  demonstration.  Of  course,  in  this  as  in  the  other  instances 
cited  disease  is  caused  not  by  the  organic  matter,  but  by  the  specific 
bacteria  with  which  the  organic  matter  is  usually  associated. 


^*  Quoted  in  Parkes,  op.  cit.,  p.  48;    Nowak,  Lehrbuch  der  Hygiene,  p.  51; 
and  in  numerous  other  publications  on  Hygiene. 

5 


66  TEXT-BOOK  OF  HYGIENE. 

It  must  not  be  forgotten  that  the  ova  of  certain  animai  para- 
sites, such  as  distoma  hematobium,  filaria  sanguinis  hominis,  and 
medinensis,  anchylostoma  duodenale,  and  possibly  of  round-worm  are 
frequently  present  in  polluted  water. 

The  relation  of  typhoid  fever  to  the  water-supply  is  probably  the 
most  important  phase  of  the  study  of  water  from  a  hygienic  stand- 
point. Typhoid  fever  is  the  disease  most  frequently  caused  by  sew- 
age-polluted water,  and  next  to  tuberculosis  and  pneumonia  it  is  the 
principal  cause  of  sickness  and  death.  There  occur  annually  in  the 
United  States  about  50,000  deaths  from  typhoid  fever,  the  estimated 
number  of  cases  being  at  least  500,000.  The  manner  in  which 
t3^phoid  fever  is  caused  by  a  polluted  water-supply  is  as  follows: 
The  cause  of  typhoid  fever  is  a  bacillus  discovered  by  Eberth  and 
Koch,  in  1880,  and  first  isolated  and  studied  in  pure  culture  by 
Gaffky,  in  1884.  This  bacillus  is  taken  in  with  the  food  and  drink 
which  contain  it,  and  is  excreted  from  the  body  of  the  typhoid  fever 
patient  with  the  feces.  The  latter  gains  access  to  the  nearest  water- 
suppl}^,  and  the  typhoid  bacilli  infect  the  water,  which  becomes  the 
means  of  conveying  the  bacilli  to  other  susceptible  individuals.  In 
this  way  epidemics  of  typhoid  fever  originate  in  towns  and  cities 
which  are  obliged  to  drink  the  sewage  of  other  municipalities  located 
on  their  watershed.  Of  course,  there  is  always  a  possibility  of  direct 
infection  by  coming  in  contact  with  the  patient's  feces  or  urine,  but 
such  mode  of  transmission,  while  possible  in  isolated  cases,  cannot 
result  in  epidemics. 

Many  instances  are  on  record  where  outbreaks  of  tj^phoid  fever 
have  been  clearly  attributable  to  pollution  of  the  drinking-water  by 
the  germ  of  the  disease  from  a  previous  case. 

One  of  the  most  remarkable  of  these  outbreaks  is  that  recorded 
by  Dr.  Thorne.^^  About  the  end  of  January,  1879,  typhoid  fever  be- 
gan suddenly  in  the  adjoining  towns  of  Caterham  and  Eed 
Hill.  Within  six  weeks  353  cases  occurred.  All  other  sources  of  the 
disease  were  excluded  except  the  drinking-water,  to  pollution  of  which 
it  was  traced  with  almost  absolute  certainty.  Caterham  contained  558 
houses  and  Eed  Hill  1700.  Of  the  former  419  and  of  the  latter  924 
drew  their  drinking-water  from  a  common  supplj'',  having  its  source 
in  a  well  several  hundred  feet  deep.  The  insane  asylum,  with  2000 
inmates,  and  the  military  barracks  in  Caterham  used  water  from  a 
private  well.     There  was  no  typhoid  fever  among  the  last  two  com- 


*'  Report  of  the  medical  officer  to  the  Local  Government  Board  for  1879. 
Quoted  in  Fodor:    Hygienische  Untersuchungen,  etc.,  II  Abth.,  p.  261. 


DISEASES  DUE  TO  IMPURE  DRINKING-WATER.  67 

mimities.  During  January  one  of  the  workmen  engaged  in  some 
excavation  near  the  public  well  was  taken  ill  with  diarrhea  and  fever, 
— probably  typhoid — but  was  still  able  to  continue  his  work.  His 
dejections  were  often  voided  where  they  were  certain  to  become 
mingled  with  the  water  of  the  common  supply.  This  man's  diarrhea 
began  on  January  5th  and  continued  until  the  20th  of  the  month, 
during  which  time  he  remained  at  work.  On  the  latter  date  he  was 
compelled  to  quit  work  and  take  to  his  bed.  Exactly  two  weeks  from 
the  beginning  of  the  man's  sickness,  on  January  19th,  the  first  case 
of  typhoid  occurred  in  Caterham,  and  then  rapidly  increased.  The 
first  case  occurred,  therefore,  just  fourteen  days — the  incubative 
period  of  typhoid — after  the  presumed  infection  of  the  drinking- 
water  by  the  dejections  of  the  sick  laborer,  who  had  come  from  Croy- 
don, where  typhoid  fever  was  at  the  time  prevalent.  Within  two 
weeks  from  the  appearance  of  the  first  case  the  epidemic  had  reached 
its  height,  and  then  rapidly  declined,  disappearing  almost  entirely 
in  a  month  after  the  outbreak.  It  was  shown  by  Dr.  Thorne  that 
nearly  all  the  houses  in  which  the  disease  appeared  were  supplied 
with  water  from  the  source  above  mentioned,  while  other  houses  in 
the  immediate  vicinity  of  the  infected  ones  remained  free  from  the 
disease. 

In  1874  there  was  an  outbreak  of  typhoid  fever  in  the  town  of 
Over  Darwen,  in  which  nearly  10  per  cent,  of  the  inhabitants  were 
attacked.  Here  the  source  of  the  disease  was  also  traced  to  an  in- 
fected water-supply. 

Dr.  Buchanan  has  shown  that  an  outbreak  among  the  students 
of  the  University  of  Cambridge  was  likewise  attributable  to  an  in- 
fected water-supply. 

.  In  1885  an  epidemic  of  typhoid  fever  began  in  Plymouth,  a 
mining  town  of  8000  or  9000  inhabitants,  situated  in  the  Wyoming 
coal  region  of  Pennsylvania,  and  on  the  right  bank  of  the  Susque- 
hanna Eiver.  The  epidemic  began  in  April,  and  lasted  until  the 
ensuing  September.  There  were  1104  persons  attacked  by  the  disease, 
of  which  number  114,  or  10.3  per  cent.,  died.  The  careful  inspection 
made  into  the  history  of  this  epidemic  revealed  the  fact  that  the  public 
water-supply  had  unquestionably  become  polluted  by  the  fecal  dis- 
charges of  a  single  person  who  Avas  affected  with  the  disease.  This 
man  had  visited  Philadelphia  on  December  25.  1884,  and  while  there 
contracted  typhoid  fever.  He  returned  to  his  home,  on  the  banks 
of  the  stream  from  which  Plymouth  derived  its  water-supply,  in 
January,  and  was  ill  for  several  weeks.     During  his  illness  the  fecal 


68  TEXT-BOOK  OF  HYGIENE. 

discharges  that  were  passed  during  the  night  were  thrown  upon  the 
snow  within  a  few  feet  of  the  stream.  From  March  21st  to  March  23d 
a  thaw  occurred,  and  during  the  early  days  of  April  there  were  fre- 
quent warm  showers.  As  a  result,  the  entire  mass  of  dejecta  which 
accumulated  during  this  man's  illness  was  washed  directly  into  the 
stream.    About  two  weeks  later  the  epidemic  broke  out. 

In  1895,  Grand  Forks,  IST.  D.,  a  village  of  about  6000  population, 
had  1500  to  2000  cases  (25  per  cent,  of  her  population)  and  about  200 
deaths. 

Previous  to  the  epidemic  the  city  water-supply  was  taken  from 
the  Bed  Lake  Eiver,  which  is  a  small,  unnavigable  stream.  Twenty- 
four  miles  above  Grand  Forks,  by  car  line,  Crookston  is  situated,  with 
a  population  at  that  time  of  about  3000.  During  the  summer  of 
189-1  they  had  a  good  many  cases  of  typhoid  fever  at  Crookston. 
Their  main  sewer  passed  under  one  of  the  railroad  embankments 
just  before  emptying  into  the  Eed  Lake  Eiver.  Some  time  during 
the  summer  the  embankment  crushed  in  the  sewer,  shutting  it  off. 
The  sewage  then  came  to  the  surface  and  formed  a  small  stagnant 
pond  held  back  l)y  the  embankment.  This  remained  for  about  two 
months,  continually  increasing  in  amount.  Just  about  the  time  that 
ice  formed  on  the  Eed  Lake  Eiver  this  sewer  under  the  track  was 
opened  up  and  the  dammed-back  pond  of  sewage  allowed  to  flow  out 
rapidly  underneath  the  ice.  This  was  the  time  of  year  when  the  water 
in  the  river  would  be  quite  low,  so  that  there  was  little  chance  for 
proper  dilution  and  aeration.  As  a  result,  some  two  or  three  weeks 
after  this  sewage  was  opened,  the  young  people  of  Grand  Forks  took 
sick  by  the  dozens,  then  by  the  hundreds.  The  degree  of  virulency 
seemed  to  be  unusually  severe. 

In  1903,  Ithaca,  X.  Y.,  the  home  of  Cornell  University,  was 
stricken  by  a  severe  epidemic  of  typhoid  fever.  Of  a  population  of 
13,000,  1350  took  sick  and  78  died.  The  cause  was  traced  to  the 
pollution  of  the  water-supply. 

During  the  same  year  an  epidemic  of  typhoid  fever  occurred  in 
Butler,  Pa.,  a  city  of  18,000  population,  in  which  1348  persons  were 
stricken  within  the  short  period  of  ninety  days  and  111  deaths 
occurred,  as  given  in  the  report  of  the  State  Board  of  Health.  This 
town  was  supplied  with  water  from  a  stream  more  or  less  polluted,  but 
just  prior  to  the  epidemic  the  private  water  company  installed  a  me- 
chanical filter  which  was  doing  satisfactory  work  until  October,  when, 
on  account  of  the  changes  in  the  pumping  station,  the  filter  was  shut 


DISEASES  DUE  TO  IMPURE  DRINKING-WATER.  69 

off  at  intervals  to  allow  work  to  proceed  on  these  changes ;  and  imme- 
diately there  appeared  the  epidemic. 

Within  ten  days  after  the  polluted  water  began  to  be  pumped 
direct  the  physicians  were  overwhelmed  with  calls.  .  By  N'ovember 
39th  the  disease  was  so  widespread  and  serious  that  a  public  mass 
meeting  was  called  and  a  relief  committee  organized.  In  order  to 
meet  the  expense  of  the  committee  $25,000  was  voluntarily  sub- 
scribed and  it  was  estimated  that  $75,000  would  be  needed.  Xurses 
and  physicians  were  procured  from  Pittsburg,  Philadelphia,  and  other 
places.  The  work  at  the  station  was  rushed  to  completion  at  the 
earliest  possible  moment,  but  to  December  17,  1903,  there  was  a  total 
of  1270  cases  reported,  with  56  deaths. 

In  this  case  the  infection  was  traced  to  the  drainage  from  a 
miner's  cabin  in  which  there  was  typhoid  fever.  The  drainage  from 
this  cabin  was  directly  into  a  small  branch,  the  flow  from  which  en- 
tered into  the  stream  from  which  the  supply  was  taken,  at  a  point 
a  few  yards  above  the  intake  to  station. 

In  1904  an  epidemic  of  typhoid  fever  occurred  in  Columbus, 
Ohio,  with  a  population  of  140,000.  The  number  of  cases  was 
1640,  number  of  deaths  166.  The  source  of  the  epidemic  was  traced 
to  the  pollution  of  the  Scioto  Elver  with  the  sewage  from  the  State 
Hospital. 

Quite  recently  a  severe  epidemic  of  tj^hoid  fever  occurred  in 
Scranton,  Pa.  This  epidemic  was  investigated  by  Dr.  Eobin  and  the 
following  are  excerpts   from  his   report: — 

"A  visit  to  the  Bureau  of  Health  showed  at  a  glance  the  serious- 
ness of  the  conditions  as  well  as  the  determined  eifort  on  the  part 
of  the  officials  to  meet  them  successfully.  Every  desk  in  the  office 
had  behind  it  a  busy  worker.  Dr.  Keller,  the  superintendent,  was 
busily  engaged  receiving  reports  and  giving  orders.  Every  few  min- 
utes a  messenger,  police  officer,  or  inspector  came  in  with  a  report 
and  for  instructions.  Physicians  came  in  for  information,  and  the 
telephones  were  in  constant  use.  The  whole  aspect  reminded  one 
of  army  headquarters  during  an  imjDortant  battle. 

"On  December  3,  1906,  5  cases  of  t3'phoid  fever  were  reported 
to  the  Bureau  of  Health.  From  that  date  to  December  12th,  20  cases 
were  reported.  There  is  every  reason  to  suppose  that  typhoid  cases 
occurred  prior  to  that  date,  and  in  larger  numbers  than  were  reported, 
the  attending  physicians  having  diagnosed  them  as  grippe.  On  De- 
cember 12,  24  cases  were  reported,  and  from  that  date  up  to  January 


70  TEXT-BOOK  OF  HYGIENE. 

5,  1907,  the  number  of  cases  reported  reached  970,  with  77  deaths 
attributed,  of  which  55  were  officially  reported. 

"The  cases  of  typhoid  fever  are  practically  confined  to  the  central 
part  of  the  city  and  West  Scranton,  which  were  supplied  with  high 
service  from  the  Elmhurst  Eeservoir,  The  disease  does  not  appear 
to  be  confined  to  any  particular  class  of  people,  the  rich  and  poor 
suffering  alike,  nor  is  there  any  relation  of  the  epidemic  to  the  sani- 
tary conditions  of  certain  sections  of  the  city.  While  the  poor  suffer 
most  on  account  of  a  lack  of  means,  and  their  sufferings  are  more  in 
evidence,  the  well-to-do  and  the  rich  contribute  their  full  quota  to  the 
morbidity  and  mortality  list.  The  deaths  of  many  prominent  men 
and  women  have  already  been  chronicled,  and  many  a  happy  home 
has  been  shattered  by  this  dread  disease. 

"The  consensus  of  opinion  of  all  the  officials,  loc^l  as  well  as  State, 
with  the  exception  of  the  Scranton  Gas  and  Water  Company,  is  that 
the  water  supply  is  to  blame  for  the  ei^idemic.  The  city  of  Scranton, 
with  a  population  of  about  120,000,  is  supplied  with  water  obtained 
from  mountain  streams.  These  are  intercepted  by  four  small  stor- 
age reservoirs  of  about  1,000,000  gallons  each,  and  merge  into  what 
is  known  as  Eoaring  Brook.  The  latter  empties  into  the  Elmhurst 
Storage  Eeservoir  of  a  capacity  of  1,600,000,000  gallons,  and  from 
this,  overflowing  a  dam,  passes  through  a  pipe  to  No.  7  reservoir, 
from  which  the  city  is  ordinarily  supplied.  A  pipe-line  also  passes 
from  the  Elmhurst  reservoir  to  Lake  Scranton,  a  storage  reservoir  of 
2,000,000,000  gallons  capacity.  When  the  flow  over  the  dam  at  the 
Elmhurst  Eeservoir  is  insufficient  to  supply  the  city,  the  supply  is 
augmented  by  drawing  on  Lake  Scranton.  The  watershed  is  sparsely 
populated  and  there  are  no  large  centres  of  pollution,  the  only  village 
of  any  size  being  Moscow,  with  a  population  of  about  900,  which 
drains  directly  into  the  Eoaring  Brook.  However,  two  railroad  lines 
pass  along  the  branches  of  the  Eoaring  Brook,  the  Erie  and 
D.,  L.  &  W.,  and  these  form  a  possible  source  of  pollution. 

"The  water-works  are  owned  by  the  Scranton  Gas  and  Water  Com- 
pany and  are  estimated  by  the  owners  to  bo  worth  $13,000,000. 

"The  water  has  been  of  good  quality  and  there  is  no  record  of  any 
marked  pollution  of  the  supply,  nor  wou^d  the  mortality  of  typhoid 
fever  in  the  past  indicate  that  the  supply  was  not  comparatively  pure. 
In  the  report  of  the  Bureau  of  Health  for  1905,  the  following  state- 
ment is  made : — 

"  ^The  city  of  Scranton  can  proudly  boast  of  its  pure  and  unlimited 
water  supply,  as  also  the  protection  given  to  its  water-sheds.    The  bac- 


DISEASES  DUE  TO  IMPURE  DRINKING-WATER.  7I 

teriologist,  Dr.  Wilson,  has,  on  numerous  occasions,  examined  speci- 
mens from  the  different  reservoirs  at  different  times,  and  found  them 
in  excellent  condition.'  This  statement  seems  to  find  corroboration 
in  the  low  typhoid  fever  mortality,  the  deaths  from  typhoid  fever 
being  in  1905-1906,  11  and  25  respectively. 

"However,  amidst  all  this  security  and  confidence,  the  blow 
struck.  Whether  the  sudden  contamination  of  the  water-supply 
came  from  passengers  suffering  or  convalescent  from  a  mild  form  oi 
typhoid  fever,  on  either,  or  both  of  the  railroads;  whether  it  came 
from  one  or  more  of  the  hunters  who  have  hunted  on  the  water-shed; 
whether  from  some  visitor  at  the  hotel  at  Moscow,  which  drains  into 
the  Eoaring  Brook,  is  not  known.  The  fact,  however,  is  that  the  sup- 
ply in  the  Elmhurst  Eeservoir  was  found  badly  polluted,  and  what 
is  of  the  greatest  importance,  the  typhoid  bacilli  have  been  actually 
discovered  in  some  of  the  samples  of  water  analyzed  at  the  State 
Laboratories  at  Harrisburg.  This,  I  believe,  is  the  first  instance  in 
this  country  of  actually  demonstrating  the  presence  of  typhoid  bacilli 
in  water  suspected  of  causing  typhoid  fever.  In  view  of  this  fact, 
I  made  special  inquiries,  and  was  assured  by  Dr.  Johnson  and  Mr. 
Snow  that  the  bacillus  which  the  State  bacteriologist  isolated  from  the 
water,  responded  to  all  the  cultural  and  other  tests,  and  was  found 
identical  with  the  typhoid  bacillus  isolated  from  the  discharges  from 
typhoid  patients  at  Scranton.  This  remarkable  and  unique  demon- 
stration establishes  beyond  doubt  not  only  the  cause  of  the  Scranton 
epidemic,  but  the  relation  of  water-supplies  to  typhoid  epidemics  in 
general. 

"As  a  result  of  these  findings  the  supply  from  Elmhurst  Eeservoir 
has  been  cut  off  and  the  city  of  Scranton  is  supplied  from  Lake  Scran- 
ton. As  a  further  precaution,  the  health  authorities  have  urged  the 
people  to  boil  the  water  and  milk,  a  precaution  which  is  generally 
being  observed. 

"It  should  be  noted  that  the  health  authorities  have  shown  re- 
markable ability  and  zeal  in  coping  with  the  serious  situation.  Daily 
bulletins  apprise  the  people  of  the  exact  situation,  while  thorough 
disinfection  of  the  premises  is  rigorously  enforced.  The  hospitals 
and  charitable  institutions  have  lent  their  entire  forces  to  meet  the 
conditions  prevailing  at  the  present  time,  while  the  press  has  all 
along  supported  and  helped  the  administration.  As  a  result  there  is 
no  panic.  The  situation  is  viewed  calmly  and  sensibly,  and  there  is 
every  reason  to  believe  that  the  epidemic  will  soon  be  under  control. 
"The   Scranton   epidemic   still   further   emphasizes  the  fact,   long 


72 


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76  TEXT-BOOK  OF  HYGIENE. 

ago  recognized  in  Europe,  that  no  surface  water  is  safe  without  j&nal 
purification,  and  that  an  ounce  of  prevention  is  worth  many  pounds 
of  cure." 

Tlie  above-cited  epidemics  emphasize  the  danger  confronting 
every  municipality  in  this  country  that  depends  on  a  surface  water 
for  its  supply.  In  fact,  Pittsburg  and  Allegheny,  and  Philadelphia, 
are  subjected  to  annual  typhoid  epidemics  which,  in  point  of  destruc- 
tion of  human  lives,  exceed  any  other  agency  of  death.  For  the  last 
14  years  there  have  been  reported  in  Pittsburg  some  30,000  cases  and 
over  4200  deaths. 

The  relation  of  typhoid  fever  to  the  water-supply  of  the  large 
American  cities  is  best  shown  in  the  table  on  pages  72  to  75. 

On  the  other  hand,  Hague,  Berlin,  Eotterdam,  Breslau,  Ham- 
burg, Zurich,  Amsterdam,  London.  Edinljurgh,  and  Warsaw,  European 
cities  supplied  with  water  filtered  through  slow  sand  filters,  have  an 
average  typhoid  mortality  of  8.3  per  100,000. 

As  it  is  with  typhoid  fever,  so  also  with  cholera.  In  the  instance 
to  be  presently  noted  the  connection  between  the  infected  water,  on 
one  hand,  and  the  outbreak  of  cholera,  on  the  other,  is  so  clearly 
shown  as  to  be  almost  equivalent  to  a  mathematical  demonstration. 
The  facts  in  the  case  were  brought  to  light  after  a  patient  inquiry  by  a 
commission,  whose  report  drawn  up  by  Mr.  John  Marshall  has  made 
the  occurrence  classical.  In  1854  the  people  of  a  Avell-to-do  and  other- 
wise healthy  district  in  the  eastern  part  of  London  suffered  severely 
from  cholera.  L^pon  inquiry  the  fact  was  elicited  that  a  child  had 
died  of  cholera  at  No.  40  Broad  Street,  and  that  its  excreta  had  been 
emptied  into  a  cess-pool  situated  only  three  feet  from  the  well  of  a 
public  pump  in  that  street,  from  which  most  of  the  neighboring 
people  took  their  drinking-water.  It  was  further  discovered  that  the 
bricks  of  the  cess-pool  wall  were  loose  and  permitted  its  contents  to 
drain  into  the  pump-well.  (It  should  be  noted  that  the  communica- 
tion between  the  cess-pool  and  the  well  was  direct;  that  there  was 
immediate  drainage,  not  percolation  through  the  soil.)  In  one  day 
140  to  150  people  were  attacked,  and  it  was  found  that  nearly  all  the 
persons  who  had  the  malady  during  the  first  fcAV  days  of  the  outbreak 
drank  the  water  from  the  pump.  When  the  pump  was  closed  to  public 
use  by  the  authorities  the  epidemic  subsided.  The  most  singular  case 
connected  with  this  outbreak  was  the  following:  In  West  End, 
Hampstead,  several  miles  away  from  Broad  Street,  there  occurred 
a  fatal  case  of  cholera  in  a  woman  59  years  old.  This  woman  formerly 
lived  in  Broad  Street,  but  had  not  been  there  for  many  months.     A 


STORAGE  AND  PURIFICATION  OF  WATER.  77 

cart,  however,  went  daily  from  Broad  Street  to  West  End,  carrying, 
among  other  things,  a  large  bottle  of  water  from  the  pump  referred  to. 
The  old  lady  preferred  this  water  to  all  others,  and  secured  a  daily 
supply  in  the  manner  stated.  A  niece,  who  was  on  a  visit  to  the  old 
lady,  drank  of  the  same  water.  She  returned  to  her  home,  in  a  high 
and  healthy  part  of  Islington,  was  likewise  attacked  by  cholera  and 
died.  There  were,  at  this  time,  no  other  cases  of  cholera  at  West  End, 
nor  in  the  neighborhood  of  these  last  two  persons  attacked. 

Most  of  the  English  medical  officers  in  India  hold  strongly  to  the 
view  that  cholera  is  spread  by  polluted  drinking-water,  and  the  evi- 
dence in  its  favor  is  very  strong. 

In  1885  Dr.  Eobert  Koch  discovered  the  cholera  spirillum  in  a 
water-tank  in  Calcutta,  used  as  a  source  of  domestic  supply,  and  in 
this  way  furnished  another  link  in  the  chain  of  evidence  connecting 
the  spirillum,  the  drinking-water,  and  the  outbreak  of  the  disease. 

The  evidence  in  favor  of  the  influence  of  impure  drinking-water 
on  the  causation  of  other  diseases  than  those  mentioned  is  not  suffi- 
cient to  justify  any  conclusions  at  present. 

The  source  of  a  water-supply  may  be  pure,  yet  pollution  may 
occur  before  the  water  is  used  by  persons  to  whom  it  is  distributed. 
Supply-pipes  may  become  defective,  and  the  water  become  contamin- 
ated with  sewage  or  other  deleterious  substances. 

Aside  from  the  practical  question  of  the  causation  of  disease  by 
polluted  water,  a  more  abstract  and  esthetic  idea  is  involved  in  con- 
sciously taking  any  impurity  into  the  system.  The  instincts  of  man, 
as  well  as  of  most  animals,  revolt  at  it.  These  inborn  instincts,  which 
constitute  the  sanitary  conscience,  as  Soyka  says,  demand  purity  of 
food  and  water,  as  they  insist  on  cleanliness  of  the  body,  of  clothing, 
and  of  the  dwelling. 

STORAGE    AND    PURIFICATION    OF    WATER. 

Wherever  a  large  supply  of  water  is  needed,  unless  drawn  direct 
from  a  well  or  spring,  or  pumped  directly  from  its  source,  arrange- 
ments for  storage  are  necessary.  Cisterns  and  large  reservoirs  are 
made  use  of  for  this  purpose.  Eiver-water,  especially,  requires  a 
period  of  rest,  in  a  storage  reservoir,  in  order  to  allow  deposition  of  the 
large  amount  of  suspended  matter  in  it.  Prolonged  storage  also  gives 
opportunity  for  the  conversion  of  possibly  deleterious  organic  com- 
pounds into  simple  and  perhaps  harmless  combinations.  Usually,  in 
an  elaborate  system  of  water-works,  a  series  of  reservoirs  is  built,  in 


78  TEXT-BOOK  OF  HYGIENE. 

which  the  water  is  stored  successively,  so  that  before  its  final  distribu- 
tion through  the  street-mains  it  has  become  quite  clear  and  pure. 
Filtration  on  a  large  scale  is  also  used  in  connection  with  storage 
reservoirs  in  order  to  secure  greater  purity  of  the  water. 

In  the  distribution  of  water,  care  should  be  taken  that  nothing 
deleterious  is  taken  up  by  the  water  in  its  passage  through  the  pipes. 
Lead-poisoning  is  not  infrequent  from  drinking-water  that  has  passed 
through  a  long  reach  of  lead  pipe,  or  which  has  been  standing  in  a 
vessel  lined  with  lead.  Tanks  and  storage  systems  should  therefore 
not  be  lined  with  lead,  and  the  use  of  lead  pipe  in  the  supply  service 
should  be  avoided  as  much  as  possible.  Fortunately,  most  natural 
waters  possess  a  considerable  portion  of  carbon  dioxide,  which  forms 
with  the  lead  an  almost  insoluble  carbonate  of  lead.  This  carbonate 
of  lead  is  deposited  on  the  inside  of  the  pipes,  and  protects  both  the 
pipes  against  erosive  action  from  other  constituents  of  the  water,  and 
also  prevents  the  contamination  of  the  water  by  the  lead.  An  excess 
of  carbon  dioxide  in  the  water  renders  this  deposit  soluble,  and  may 
cause  serious  poisoning.  Any  water  which  is  shown  by  analysis  to 
contain  over  1  milligramme  of  lead  per  100,000  is  dangerous  and 
should  be  rejected. 

Owing  to  the  possibility  of  defilement  of  the  water  from  improper 
construction  of  hydrants,  all  outdoor  hydrants  should  be  discouraged 
as  much  as  possible,  and  should  be  replaced  by  a  simple  tap-cock 
indoors.  The  pipes  should  also  be  laid  deep  enough  under-ground, 
or  otherwise  protected  against  freezing  in  winter. 

A  number  of  methods,  all  more  or  less  efficient,  have  been  intro- 
duced to  purify  water  when  it  needs  purification  before  being  fit  for 
use.  These  methods  either  comprise  filtration  or  seek  to  purify  the 
water  without  the  aid  of  this  process.  One  of  the  methods  of  puri- 
fication without  filtration  consists  in  exposing  the  water  to  the  air 
in  small  streams.  This  was  proposed  by  Lind,  more  than  a  century 
ago,  and  has  since  been  frequently  revived.  The  water  is  passed 
through  a  sieve,  or  a  perforated  tin  or  wooden  plate,  so  as  to  cause 
it  to  fall  for  a  distance  through  the  air  in  finely-divided  currents. 
By  this  process  sulphuretted  hydrogen,  offensive  organic  vapors,  and 
possibly  dissolved  organic  matters  are  removed.  This  process  has 
been  used  in  Eussia  on  a  large  scale. 

By  boiling  and  agitation,  carbonate  of  lime,  sulphuretted  hydro- 
gen, and  organic  matter  are  removed  or  rendered  innocuous.  Vege- 
table germs  are  usually  destroyed,  although  Tyndall  has  shown  that 
some  bacterial  germs  withstand  a  temperature  higher  than  that  of 


STORAGE  AND  PURIli*ICATION  OF  WATER.  79 

boiling  water.  Pathogenic  germs  are,  however,  all  destroyed  by  boil- 
ing water  acting  on  them  for  ten  minutes,  as  shown  by  Dr.  G.  j\I. 
Sternberg.^* 

As  has  already  been  mentioned/^  alum  is  one  of  the  readiest  and 
most  efficient  means  of  removing  suspended  matters  from  water. 
However,  it  should  not  be  used  in  large  quantities. 

Permanganate  of  potassium  is  sometimes  used  to  purify  water 
containing  considerable  organic  matter.  The  permanganate  rapidly 
oxidizes  the  organic  matter,  and  is  believed  to  render  it  harmless. 
There  is  no  certainty,  however,  that  the  germs  of  specific  diseases  are 
destroyed  by  the  action  of  this  salt,  in  the  proportion  in  which  it 
could  be  used  for  the  purposes  of  water  purification. 

A  yellow  tint  is  given  to  the  water  by  the  permanganate,  which  is 
due  to  finely-divided  peroxide  of  manganese.  This  does  no  harm, 
but  is  unpleasant.  Bromine  has  been  used  for  a  similar  purpose,  and 
is  claimed  to  give  very  good  results.  The  bromine  may  be  neutralized 
by  ammonium  or  other  alkali. 

In  1904,  Moore  and  Ivellerman,^*'  of  the  Bureau  of  Plant  Indus- 
try, United  States  Department  of  Agriculture,  advocated  the  use  of 
copper  sulphate,  first  for  the  destruction  of  algae,  and  later  for  the 
purification  of  water.  They  found  that  in  proportion  of  1  :  100,000 
copper  sulphate  is  an  efficient  germicide,  destroying  the  colon  and 
typhoid  bacilli.  It  was  also  discovered  that  copper  vessels  are  capable 
of  purifying  water  through  action  of  the  colloidal  copper  which  is 
taken  up  by  the  contents.  For  a  time  these  claims  received  enthusi- 
astic endorsement  from  many  quarters,  and  it  seemed  as  though  the 
difficult  problem  of  water-purification  in  a  ready  manner  had  been 
satisfactorily  solved.  However,  the  enthusiasm  cooled  down  consider- 
ably when  reports  began  to  appear  from  various  laboratories,  show- 
ing that  the  claims  of  Kellerman  and  his  followers  are  greatly  over- 
drawn. Aside  from  the  fact  that  it  would  not  be  safe  to  introduce 
copper  sulphate  into  the  system,  even  in  minute  and  theoretically 
harmless  quantities,  for  a  long  time,  the  fact  has  been  brought  out 
that  the  germicidal  action  of  copper  is  very  uncertain.  Among  the 
bacteriologists  who  reported  adversely  to  this  new  method,  Clark 
and  Gage,  of  the  Lawrence  Experiment  Station,  have  furnished  the 
most  damaging  evidence.  In  an  article  on  the  bactericidal  action 
of  copper^'^  the  authors  very  properly  emphasize  that  "the  weak  point 

"  Report  of  Committee  on  Disinfectants,  1888. 

"  See  page  64. 

"U.  S.  Dep't  A^mculture.    Bur.  Plant  Ind.,  Bull.  No.  64. 

"The  Jour,  of  Inf.  Diseases,  Supplement  No.  2,  Feb.,  1906. 


80  TEXT-BOOK  OF  HYGIENE. 

in  tlie  conclusions  of  Moore  and  Kellerman  with  regard  to  the  de- 
struction of  typhoid  by  copper  is  that  they  were  drawn  from  analy- 
ses in  which  the  largest  amount  of  water  tested  was  1  c.  c,  and  the 
usual  amount  tested  was  less  than  .01  c.  c,  It  is  generally  conceded, 
especially  when  dealing  with  laboratory  cultures,  that  the  great  ma- 
jority of  the  typhoid  bacilli  are  quickly  destroyed  by  conditions  un- 
favorable to  their  growth.  It  has  also  been  repeatedly  shown  that  a 
few  germs  are  much  more  resistant  than  the  majority,  and  may  sur- 
vive even  under  the  most  unfavorable  conditions  for  many  days.  All 
epidemiological  evidence  points  to  the  conclusion  that  the  germs  which 
are  able  to  live  under  unfavorable  conditions  are  also  extremely  patho- 
genic, and  that,  while  it  may  help  to  destroy  the  majority  of  the 
bacilli,  no  method  of  sterilizing  water  is  thoroughly  effective  unless 
it  will  accomplish  the  destruction  of  the  especially  resistant  indi- 
viduals. 

"It  is  unsafe  to  conclude  that  because  a  certain  species  of  bac- 
teria, especially  a  pathogen  like  B.  typhosus,  is  not  found  in  a  loopful 
of  the  water,  or  even  in  1  c.  c,  that  there  is  no  danger  from  the  use 
of  that  water.  The  average  drinking-glass  holds  about  300  c.  c,  and 
until  repeated  tests  of  volumes  as  large  as  100  c.  c.  have  been  made 
and  the  germ  proved  to  be  absent,  the  water  under  observation  can- 
not safely  be  said  to  be  free  from  the  test  forms." 

The  authors  have  used  large  quantities  of  water  in  their  experi- 
ments and  have  varied  the  experiments  to  cover  the  ground  thor- 
oughly.    Their  conclusions  are: — 

"The  treatment  of  water  with  copper  sulphate  or  by  storing  it  in 
copper  vessels  has  little  practical  value,  for  the  following  reasons: — 

"1.  The  use  of  any  method  of  sterilization  which  is  not  absolutely 
effective  is  dangerous  in  the  hands  of  the  general  user,  tending  to 
induce  a  feeling  of  false  security,  and  leading  to  the  neglect  of  or- 
dinary precautions  which  would  otherwise  be  employed. 

"2.  The  removal  of  bacteria,  B.  coli  and  B.  tj^phosus,  by  allowing 
a  water  to  stand  in  copper  vessels  for  short  periods,  while  occasionally 
effective,  is  not  sure,  and  the  time  necessary  to  accomplish  complete 
sterilization  is  so  long  that  the  method  would  be  of  no  practical  value 
to  the  ordinary  user.  Furthermore,  metallic  copper  seems  to  have 
little  more  germicidal  power  than  iron,  tin,  zinc,  or  aluminum. 

"3.  Although  the  removal  of  B.  coli  and  B.  typhosus  is  occasion- 
ally accomplished  by  dilute  solutions  of  copper  sulphate,  these  organ- 
isms may  both  live  for  many  weeks  in  water  containing  copper  sul- 
phate in  greater  dilutions  than  1  :  100,000;   and  in  order  to  be  safe 


STORAGE  AND  PURIFICATION  OF  WATER.  81 

dilutions  of  1  :  1000  must  be  used,  in  which  case  the  water  becomes 
repugnant  to  the  user  because  of  its  strongly  astringent  taste. 

"4.  In  some  instances  very  dilute  solutions  of  coj^per  sulphate  or 
colloidal  copper  absorbed  from  contact  with  clean  metallic  copper, 
appear  to  have  a  decidedly  invigorating  effect  on  bacterial  activity, 
causing  rapid  multiplication,  when  the  reverse  would  have  been  true 
had  the  water  been  allowed  to  stand  the  same  length  of  time  without 
any  treatment." 

Eegarding  the  effect  of  copper  and  other  metals  on  B.  coli,  the 
authors  found  that  the  organism  disappears  under  the  action  of  the 
respective  metals  in  the  following  number  of  days:  zinc,  10  days; 
iron,  15  days;  tin,  41  days;  aluminum,  41  days;  copper,  43  days; 
lead,  97  days;  and  in  another  experiment:  zinc,  10  days;  copper, 
10  days;  tin,  23  days;  iron,  23  days;  lead,  23  days;  aluminum, 
31  days. 

Filtration. — The  purification  of  water  by  filtration  has  been 
shown  to  be  the  most  reliable  means  of  removing  both  suspended  mat- 
ter and  bacteria  from  polluted  water.  Filtration  is  practiced  on  a 
small  scale — domestic  filters — and  on  a  large  scale.  Of  the  domestic 
filters  only  those  made  of  unglazed  porcelain  (the  Pasteur  filters) 
or  infusorial  earth  (the  Berkefeld  filter)  are  to  be  relied  upon. 
These  filters  are  made  of  a  porous  material,  the  pores  forming  tortu- 
ous channels  in  which  the  bacteria  lodge  and  are  retained.  After 
a  time  the  filter  becomes  permeated  with  bacteria  and  the  latter  are 
pushed  through,  as  it  were,  by  the  incoming  armies.  To  make  them 
yield  a  satisfactory  effluent,  the  filtering  unit  should  be  frequently 
scrubbed  and  sterilized  in  the  oven  or  by  boiling  at  least  once  a  month. 
Maignen's  domestic  filter,  made  of  granulated  charcoal  and  asbestos, 
is  said  to  be  quite  satisfactory.  All  other  domestic  filters  on  the 
market,  and  their  name  is  legion,  are  practically  worthless,  if  not 
actually  harmful  because  of  the  false  security  which  they  give. 

On  a  large  scale,  water  may  be  purified  by  sedimentation,  slow 
sand-filtration,  or  the  English  method,  rapid  sand-filtration,  or  the 
American  method,  which  is  also  known  as  mechanical  filtration. 

In  the  process  of  sedimentation  the  water  is  confined  in  one  or 
more  large  reservoirs  holding  30,000,000  to  50,000,000  gallons  and 
allowed  to  become  clarified  by  the  particles  of  mud  falling  to  the  bot- 
tom. Incidentally,  the  bacteria  are  carried  down  and  some  oxidation 
of  the  organic  matter  takes  place.  Usually  about  75  per  cent,  of 
purification  takes  place  by  this  method.  In  St.  Louis  the  water  is 
treated  with  iron  sulphate  and  lime  before  final  sedimentation.     By 


TEXT-BOOK  OF  HYGIENE. 


STORAGE  AND  PURIFICATION  OF  WATER. 


83 


Fig.  5. — Plans  of  Intake  and  Water-tower  Used  in  Connection  with 
the  Reservoir. 


84  TEXT-BOOK  OF  HYGIENE. 

this  method  the  effect  of  sedimentation  is  greatly  enhanced  and  the 
purification  of  the  water  is  much  greater. 

Slow  Sand  FiLTRATioisr. — This  method  was  originally  employed 
by  the  London  water  companies  as  a  means  of  removing  from  the 
water  the  matter  in  suspension.  Later,  however,  Frankland  ha?  shown 
that  the  sand-filters  also  remove  the  bacteria  or  most  of  them,  and 
thus  purify  as  well  as  clarify  the  water.  Since  1890  the  Massachu- 
setts State  Board  of  Health  has  been  conducting  extensive  experi- 
ments on  slow  sand-filtration,  and  it  is  these  experiments  that  have 
elucidated  the  subject  of  filtration  and  placed  it  on  a  solid  scientific 
basis.     The  principle  underljdng  slow  sand-filtration  is  a  biologic  one. 

The  forces  which  bring  about  purification  of  the  water  in  the 
sand-filter  are  exactly  the  same  as  operate  imder  natural  conditions 
when  a  foul  surface  pool  percolates  slowly  through  the  ground  and 
crops  out  in  the  form  of  a  pure,  sparkling  spring.  The  upper  layers 
of  the  ground  swarm  with  various  bacteria  which  live  on  dead  organic 
matter,  so-called  saprophytes.  Among  them  are  certain  species  which 
convert  the  nitrogenous  substances  into  ammonia;  others  convert  the 
ammonia  into  nitrites  and  nitrates,  the  so-called  nitrifying  bacteria; 
again  others  break  up  cellulose;  in  a  word,  the  organic  substances 
of  the  water  are  attacked  from  all  sides  and  converted  into  harmless 
mineral  substances,  the  latter  to  be  taken  up  by  the  plants  as  food. 
If  any  pathogenic  bacteria  happen  to  be  present  they  find  a  strange 
and  altogether  uncongenial  environment.  In  the  first  place,  they  are 
accustomed  to  body-heat,  and  the  comparatively  low  temperature  chills 
them;  then,  they  are  parasitic  in  nature  and  cannot  prepare  food  for 
themselves,  while  the  food  that  they  find  is  rapidly  consumed  by 
their  competitors,  which  are  in  greatly  predominating  numbers. 
Thus,  the  pathogens  soon  perish  and  are  rapidly  consumed  by  the 
saprophytes.  Tliat  this  is  not  a  fanciful  representation  may  be 
demonstrated  by  laboratory  experiments,  which  will  show,  for  in- 
stance, that  anthrax  bacilli  are  rapidly  destroyed  in  putrefying  blood ; 
that  typhoid  bacilli  soon  disappear  in  feces;  that  any  of  the  patho- 
genic bacteria  are  quickly  crowded  out  in  cultures  which  contain  also 
saproph3^tic  bacteria. 

Conditions  very  much  similar  to  those  existing  in  nature  prevail 
in  the  slow  sand-filter.  Here  we  have  a  bed  of  fine  sand  about  three 
feet  thick,  through  which  the  water  percolates  at  a  rate  of  3,000,000 
to  4,000,000  gallons  per  acre  per  day.  While  the  water  passes  through 
the  sand,  the  suspended  matter  is  strained  out  and  is  deposited  be- 
tween the  sand-grains,  in  the  upper  inch  or  two.    The  infusoria,  algae, 


STORAGE  AND  PURIFICATION  OF  WATER. 


85 


and  bacteria  in  the  water  become  entangled  in  what  is  now  a  very 
fine  sieve  and  form  a  slimy  film  about  the  sand-grains,  on  the  surface 
of  the  bed.  No  sooner  are  the  various  bacteria  domiciled  than  they 
at  once  commence  to  work,  each  species  performing  its  particular 
function  and  making  a  struggle  for  existence.  The  surface  film  of 
the  sand-bed,  or  what  the  Germans  call  '^schmutzdecke"  (mud-film), 
is  now  teeming  with  life  and  is  the  field  of  energetic  biologic  activity, 
the  result  of  which  is  the  transformation  of  the  complex  organic 
molecules  into  simple  inorganic  compounds.  Any  pathogenic  bacteria 
that  may  be  present  in  the  water  become  enmeshed  in  this  film  and 
soon  perish  in  the  unfavorable  environment.    In  time  the  upper  mud- 


Fig.  6. — Plans  of  Slow  Sand  Filters.  These  consist  of  concrete 
basins,  on  the  floor  of  which  are  laid  tile  or  terra  cotta  underdrains; 
over  these,  from  three  to  six  inches  of  gravel  in  successive  layers, 
beginning  with  the  very  large  sizes  at  the  bottom  and  the  finest  at 
the  top;  over  this  about  three  feet  of  fine  sand,  and  over  this  three 
to  four  feet  of  water. 


film  becomes  more  and  more  compact,  until  only  a  comparatively 
small  amount  of  water  passes  through.  This  happens,  under  ordinary 
circumstances,  about  once  in  three  weeks.  Whan  this  occurs,  the  filter 
is  drained,  the  upper  inch  of  sand  removed  by  means  of  shovels,  and 
filtration  resumed. 

The  greatest  impetus  to  filtration  and  the  most  remarkable 
demonstration  of  its  efficiency  in  preventing  water-borne  diseases  were 
furnished  by  the  epidemic  of  cholera  which  visited  Hamburg  in  1893. 
The  cities  of  Hamburg  and  Altona  are  separated  by  an  imaginary  line, 
so  that  nothing  in  their  surroundings  or  in  the  nature  of  their  popula- 
tion distinguished  one  from  the  other.     Both  cities  depend  for  their 


86  TEXT-BOOK  OF  HYGIENE. 

water-supply  on  the  polluted  river  Elbe,  with  this  difference,  that 
while  the  intake  for  Hamburg  is  situated  above  the  city,  that  for 
Altona  is  situated  below  Hamburg,  i.e.,  the  water-supply  of  Altona 
receives  additional  pollution  of  some  800,000  inhabitants.  When 
the  epidemic  broke  out  Hamburg  suffered  a  loss  of  1250  lives  per 
100,000,  while  the  number  of  deaths  in  Altona  was  only  221.  So 
clearly  defined  was  the  path  pursued  by  the  epidemic  that  in  one 
street  which  marks  the  division  between  these  towns,  the  Hamburg- 
side  was  stricken  down  with  cholera,  whilst  that  belonging  to  Altona 
remained  free.  It  was  found  that  in  the  houses  supplied  with  the 
Hamburg  water  cholera  was  prevalent,  whilst  those  furnished  with 
Altona  water  remained  free  from  the  disease.  iSTow,  the  reason  for 
this  difference  was  in  the  fact  that  Altona  filtered  the  water,  Avhile 
Hamburg  did  not.  Fate,  moreover,  furnished  additional  proof  of  this 
fact.  During  the  ensuing  winter,  when  the  epidemic  of  cholera  had 
almost  died  out  in  Hamburg,  an  outlireak  of  the  disease  occurred 
in  Altona.  A  searching  inquiry  was  instituted  and  it  was  found  that 
instead  of  the  usual  small  number  of  bacteria  in  the  effluent  from 
the  filters,  al)out  50,  the  number  rose  to  1000  and  more  in  a  c.  c.  The 
cause  for  this  inefficiency  was  soon  discovered.  It  was  found  that 
one  of  the  sand-filters,  which  had  been  cleaned  during  the  frost,  had 
become  frozen  over,  and  was  consequently  not  able  to  retain  the  bac- 
teria. But  imperfect  as  the  filters  then  were,  they  nevertheless  saved 
the  city  from  another  severe  epidemic,  as  shown  by  the  limited  num- 
ber of  cases. 

As  a  result  of  his  studies  of  the  Altona  filters.  E.  Koch  arrived 
at  the  following  conclusions : — 

1.  The  real  effective  agent  in  removing  micro-organisms  from  the 
water  is  the  layer  of  slimy  organic  matter  which  forms  upon  the  sur- 
face of  the  sand. 

2.  If  this  surface  l^e  removed  by  scraping,  or  its  continuity  af- 
fected in  any  way,  as  by  freezing  of  the  surface,  the  number  of  bac- 
teria which  pass  through  the  filter  increases  considerably;  in  fact, 
both  cholera  and  t5rphoid  germs  may  pass  in  sufficient  numbers  to 
cause  an  epidemic  amongst  those  who  use  the  imperfectly  filtered 
water. 

3.  Filtration  should  not  exceed  a  rate  of  2,000,000  gallons  per  acre. 

4.  After  a  filter-bed  has  been  scraped,  water  should  be  allowed 
to  stand  upon  it  for  at  least  24  hours  to  allow  of  the  slime  depositing 
before  filtration  is  commenced  and  the  water  which  first  passes  should 
be  wasted. 


STORAGE  AND  PURIFICATION  OF  WATER.  87 

5.  Each  sejoarate  filter-l)cd  must,  when  in  use,  be  investigated 
bacteriologically  once  each  day. 

6.  Filtered  water  containing  more  than  100  bacteria  per  cubic 
centimetre  should  not  be  allowed  to  reach  the  pure-water  reservoir. 

Perhaps  no  single  investigation  has  contributed  as  much  towards 
our  knowledge  of  the  underlying  principles  of  filtration  as  the  experi- 
ments performed  at  the  laboratories  of  the  Massachusetts  State  Board 
of  Health  since  1890. 

The  more  important  results  of  these  experiments  may  be  sum- 
marized as  follows : — 

1.  The  depth  of  sand,  within  certain  limits,  exerts  but  little 
influence  on  the  efficiency  of  a  sand  filter,  except  when  the  rate  of  fil- 
tration is  high;  with  moderate  rapidity  of  filtration  (2,000,000  gal- 
lons per  acre  daily)  one  foot  of  sand  is  as  effective  as  five  feet. 

2.  The  effect  of  scraping  the  sand  to  remove  the  clogged  surface 
is  to  cause  an  increased  number  of  bacteria  to  pass  through  the  filter. 
Usually  the  filter  requires  three  days'  use  after  scraping  to  reach  a 
maximum  degree  of  efficiency.  The  effect  of  scraping  is  more  marked 
in  shallow  than  in  deep  filters,  and  with  high  rates  than  with  low  rates 
of  filtration. 

3.  Over  80  per  cent,  of  the  bacteria  removed  are  found  in  the 
upper  inch  of  sand,  and  55  per  cent,  in  the  upper  quarter-inch.  The 
B.  prodigiosus,  which  is  very  like  the  typhoid  bacillus  in  its  mode 
of  life  in  water,  was  not  found  below  the  upper  inch. 

4.  The  average  depth  of  sand  necessary  to  be  scraped  from  the 
surface  of  the  filter  was  ^/^  inch,  but  was  found  to  vary  with  the 
size  of  the  sand,  decreasing  as  the  fineness  of  the  sand  increased. 

5.  Much  less  water  will  pass  a  filter  at  32°  F.  than  70°  F., 
owing  to  the  increased  viscosity  of  the  water. 

6.  Within  certain  limits  and  under  equal  conditions  the  quantity 
of  water  passed  between  successive  scrapings  is  not  influenced  by  the 
rate  of  filtration. 

7.  Finer  sands  require  more  frequent  scrapings  than  coarser 
sands. 

8.  Shallow  filters  require  more  frequent  scrapings  than  deeper 
ones. 

9.  During  the  summer  months  the  temperature  and  other  con- 
ditions for  continuation  of  life  of  bacteria  at  the  surface  of  filters 
are  more  favorable  than  at  any  other  time. 

Experiments  performed  at  Wilmington,  Del.,  by  Dr.  A.  Eobin, 
indicate  that  excellent  efficiency  may  be  obtained  at  a  rate  of  4,000,- 


88  TEXT-BOOK  OF  HYGIENE. 

000  gallons  per  acre  per  day,  if  the  raw  water  is  passed,  previous  to 
filtration,  tlirongh  a  preliminary  filter,  which  removes  about  50  to 
75  per  cent,  of  the  turbidity  and  bacteria. 

Following  the  remarkable  demonstration  of  the  efficiency  of  slow 
sand-filtration  in  removing  cholera  bacilli  from  the  water,  sand-filters 
were  installed  in  almost  all  the  large  cities  of  Europe,  and  wherever 
installed  have  reduced  t^^phoid  mortality  to  a  very  small  percentage. 

In  this  country,  the  first  slow  sand-filter  was  built  by  Kirk- 
wood,  in  Poughkeepsie,  N".  Y.,  in  1877.  This  filter,  however,  was 
operated  without  any  particular  regard  to  the  scientific  aspect  of  fil- 
tration, and  under  disadvantageous  climatic  conditions. 

The  first  filter  which  has  contributed  very  largely  to  our  know- 
ledge of  the  subject,  and  which  has  served  as  a  model  for  other  plants, 
is  the  slow  sand-filter  constructed  in  Lawrence,  Mass.,  in  1893.  This 
filter  has  been  in  operation  ever  since,  giving  excellent  results  both 
as  to  the  improvement  of  the  polluted  Merrimac  water  and  the  reduc- 
tion of  the  typhoid  mortality  in  the  city.  This  is  shown  in  the  fol- 
lowing table : — 


Table 

XI. 

Death  Rate  Per  100.000. 

Year. 

Before  Filtration. 

Year. 

After  Filtration. 

1885 

42.0 

1893 

86.6 

1886 

57.5 

1894 

50.0 

1887 

117.5 

1895 

18.6 

1888 

120.0 

1896 

16.2 

1889 

137.5 

1897 

13.9 

1890 

133.3 

1898 

33.0 

1891 

122.0 

1899 

18.1 

1892 

111.1 

1900 

18.0 

Following  the  introduction  of  slow  sand-filtration  in  Lawrence, 
slow  sand-filters  have  been  constructed  in  a  number  of  American 
cities,  the  most  notable  of  which  is  Albany,  ]^.  Y.  In  the  latter  city 
a  covered  slow  sand-filter  was  constructed  by  Mr.  Hazen  in  1899. 
The  improvement  in  the  mortality  from  typhoid  fever  and  diarrheal 
diseases  has  been  very  marked,  as  shoT\Ti  by  Mr.  Bailey,  the  superin- 
tendent, in  his  report  for  the  year  ending  1901 : — 

"An  examination  of  the  health  records  of  the  city  shows  some 
interesting  features  coincident  with  the  commencement  and  continued 
operation  of  the  filter,  as  follows: — 


STORAGE  AND  PURIFICATION  OF  WATER. 


89 


Table  XII. 

Death  Record. 

General  Diarrheal  Typhoid 

Av.  Av.  Av. 
previous                 previous              previous 

10  10  10 

yrs.     1899  1900  yrs.  1899  1900  yrs.  1899  1900 

October    153     138  144  5        2        5         4        4  5 

November    162     138  135  3         0         1         5         0  4 

December 194     148  133  6         1         0         7         1  0 

1900  1901  1900  1901  1900  1901 

January 235     135  188  6         1         2  11         3  2 

February    197     146  157  6         2         0  11         1  3 

March 215     180  164  5        5         1  12         3  1 

AprU 197     202  156  4         1         0        9         5  1 

May    173     152  139  3        0         1         4        4  1 

June    159     112  145  10         7         1         4         1  3 

July    191     162  142  39  27  11         4        3  0 

August 162     116  134  21  16  14         7         6  3 

September   148     125  139  12        5  12         6        4  4 

Total  ...2186  1754  1776     120       67       48       84      35       27 
Reductions,  per  cent...   19.77    18.76    44.17    60.00    58.33    67.86 

"There  has  been  no  general  sanitary  improvement  in  the  city  in 
this  time  other  than  the  improvement  of  the  water  due  to  filtering. 
These  figures  show  facts,  and  should  be  susceptible  to  accurate  inter- 


Fig.  7. — Showing  Interior  of  Filter  Recently  Constructed  in 
Washington,  D.  C. 


90 


TEXT-BOOK  OF  HYGIENE. 


pretation.  My  inference  from  them  is,  that,  as  a  result  of  the  pure 
water  now  being  supplied,  there  is  a  better  general  condition  of 
health,  as  shown  by  a  decided  reduction  in  diseases  caused  by  filth 
and  disease-germs  that  are  water-borne." 

The  Albany  filter  has  continued  to  give  excellent  results  from  a 
sanitary  standpoint.  Slow  sand-filters  have  been  constructed  in  Prov- 
idence, E.  I.,  Washington,  D.  C,  Hudson,  IST.  Y.,  Mount  Vernon, 
N.  Y.,  Far  Eockaway,  L.  I.,  Ilion,  IST.  Y.,  Yonkers,  N.  Y.,  Somers- 
worth,  N.  H.,  Ashland,  Wis.,  Superior,  Wis.,  St.  Johnsbury,  Vt., 
Milford,  Mass.,  Nantucket,  Mass.,  Nyack,  IST.  T.,  Lambertville,  X.  J., 
Salem,  N.  J.,  Eock  Island,  111.,  Grand  Forks,  IST.  D. ;  and  are  in  the 
course  of  construction  in  Philadelphia,  Pa.,  Pittsburg,  Pa.,  and  Wil- 
mington, Del. 

Our  experience  thus  far  gained  from  the  results  of  filtration 
enables  us  to  make  the  general  proposition  that  properly  filtered  water 
is  fully  equal  in  its  hygienic  purity  to  a  pure  supply  from  natural 
sources.     This  is  shown  by  Hazen  in  the  following  table: — 


Table  XIII. 
Deaths  from  Typhoid  Fever  per  100,000  per  Annum. 


to 

(D 

<w 

a 

tao 

^ 

|5 

2  0 

6£'H 

Place 

go 

;io 

Oo 

o  a> 

g-§ 

fio 

few 

(^< 

Ph« 

Zurich,  Switzerland Filtration. 

1885 

76 

10 

87 

Hamburg,  Germany Filtration. 

1892-93 

47 

7 

85 

Lawrence,    Mass Filtration. 

1893 

121 

25 

79 

Albany,   N.  Y Filtration 

1899 

104 

28* 

73 

Lowell,  Mass.,  Kiver  water  to  ground 

water  

1895-96 

97 

21 

78 

Newark,  N.  J.,  Eiver  water  to  upland 

water 

1892 

70 

16 

77 

Jersey  City,   N.  J.,    River  water   to 

upland  water 

1896 

77 

24 

69 

Averages 

85 

19 

78 

*Fuur  years. 

Mechanical  Filters. — In  the  mechanical,  rapid  or  American 
system  of  filtration,  the  water  is  conducted  through  sand  in  about  the 
same  manner  as  in  slow  sand-filters.  In  a  mechanical  filter  the  action 
is  both  mechanical  and  chemical,  the  foreign  substances  in  the  water 


STORAGE  AND  PURIFICATION  OF  WATER.  9| 

being  retained  in  the  sand  mechanically,  while  their  retention  is 
aided  by  the  ajoplication  of  chemicals.  There  is  no  biological 
activity  in  a  mechanical  filter  as  there  is  in  the  slow  sand-process. 
By  reason  of  the  assistance  of  the  chemicals,  and  by  virtue  of  the 
absence  of  the  biological  activity  on  a  mechanical  filter,  it  can  be 
operated  at  much  higher  rates  than  slow  sand  or  '^Diological"  filters  as 
they  may  be  called.  The  usual  rate  at  which  mechanical  filters  are 
operated  is  125,000,000  gallons  per  acre  per  day,  while  slow  sand- 
filters  are  operated  at  about  the  rate  of  3,000,000  gallons  per  acre  per 
day.  A  more  rapid  passage  of  the  water  through  a  slow  sand-filter 
would  be  liable  to  wash  the  bacteria  from  the  sand-grains  about  which 
they  live,  and  so  interfere  with  the  successful  operation  of  the  filter. 

The  chemicals  usually  used  in  mechanical  filters  are  sulphate 
of  aluminum  or  sulphate  of  iron  and  lime.  The  way  these  chemicals 
act  is  as  follows:  When  sulphate  of  aluminum  is  used,  it  is  led  into 
the  supply  somewhere  before  the  water  enters  the  filters  and  there 
combines  with  the  lime  naturally  present  in  nearly  all  waters  to  form 
hydrate  of  aluminum  and  sulphate  of  calcium.  The  sulphate  of  cal- 
cium remains  in  solution  in  the  water,  but  the  hydrate  of  aluminum, 
being  insoluble,  agglomerates,  by  means  of  its  stickiness,  the  bacteria 
and  other  particles  in  suspension  in  the  water,  into  masses  of  such 
size  that  they  cannot  pass  between  the  sand-grains  as  they  would  if 
they  had  not  been  massed  together  by  the  action  of  the  chemicals. 
When  sulphate  of  iron  and  lime  are  used,  the  action  is  exactly  similar, 
only  instead  of  having  hydrate  of  aluminum  we  have  hydrate  of  iron. 
Having  all  the  foreign  particles  in  the  water  agglomerated  in  one  of 
these  ways,  they  are  much  more  easily  retained  by  the  sand  than  in 
the  slow  sand  process,  consequently  the  filter  can  be  operated  at  a 
more  rapid  rate.  Being  operated  at  a  more  rapid  rate,  the  dirt  accu- 
mulates on  the  surface  of  the  sand  faster  than  it  does  in  a  slow  sand 
plant,  with  the  consequent  necessity  of  more  frequent  cleaning. 

In  mechanical  plants  the  cleansing  of  the  sand  is  accomplished 
by  turning  a  current  of  filtered  water  upward  through  the  sand,  and 
at  the  same  time  agitating  the  whole  bed  of  sand  by  means  of  rakes 
driven  mechanically  or  by  compressed  air  forced  through  the  sand 
from  below.  By  either  means  of  agitation  the  sand-grains  are  forced 
rapidly  against  each  other  and  all  foreign  matter  is  forcibly  removed 
from  their  surfaces,  and  carried  by  the  current  of  water  to  the  top 
of  the  filter,  whence  it  is  conducted  to  the  sewer  by  pipes  arranged 
for  that  purpose.  The  operation  of  cleaning  a  mechanical  filter  usu- 
ally takes  abont  ten  minutes,  and  the  frequency  with  which  it  has 


92  TEXT-BOOK  OF  HYGIENE. 

to  be  performed  depends  entirely  upon  the  character  of  the  water 
treated.  Ordinarily  a  filter  has  to  be  cleaned  about  every  twenty- 
four  hours,  and  it  requires  from  3  per  cent,  to  5  per  cent,  of  the  fil- 
tered water  for  cleaning  purposes. 

Eegarding  the  efficiency  of  mechanical  filters,  it  may  be  said  that, 
when  carefully  constructed  and  skillfully  operated,  they  give  hy- 
gienic efficiency  equal  to  that  of  a  slow  sand-filter;  but,  on  the  other 
hand,  the  mechanism  of  operation  is  much  more  complex,  the  ^^ossi- 
bility  of  some  unlooked-for  derangement  greater,  with  consequent  lia- 
bility to  get  out  of  order  and  thus  result  in  imperfect  purification 
of  the  water. 

The  comparative  utility  of  slow  sand  and  mechanical  filters  was 
summarized  by  Col.  A.  M.  Miller,  John  W.  Hill,  and  Eudolph  Her- 
ring, acting  as  a  commission  of  experts  for  Pittsburg,  Pa.  The  fol- 
lowing is  an  extract  from  their  report,  and  the  conclusions  deduced : — 

"It  was  found  by  the  experimental  work  carried  on  by  the  former 
commission,  for  Pittsburg  conditions,  that  as  to  first  cost  mechanical 
filtration  was  the  cheaper  process.  Upon  reviewing  the  subject  at  the 
present  time,  we  are  of  the  same  opinion,  but  would  add  that  the  ex- 
pense of  operation  being  greater  for  the  mechanical  filters,  the  total 
expense  of  the  two  methods  becomes  nearly  equal,  and  the  preference 
should  depend  on  other  than  financial  considerations. 

"As  to  efficiency  in  removing  l^acteria,  the  preference  between  the 
two  methods  is  not  marked,  provided  constant  intelligent  care  is  given 
in  equal  measure  to  manipulation  of  both  processes. 

"It  cannot  be  denied,  however,  in  the  absence  of  such  care,  that 
if  any  irregularity  occurs  in  the  operation  of  the  system,  the  rapid 
or  mechanical  filter  would  present  the  greater  danger,  by  passing  a 
much  larger  quantity  of  unfiltered  water  into  the  mains,  before  a 
proper  correction  is  likely  to  be  made. 

"As  to  the  adaptability  of  the  effluent  for  steaming  purposes,  the 
weight  of  evidence  is  decidedly  in  favor  of  s^.ow  sand-filtration.  It 
was  found  by  the  Filtration  Commission  of  1897,  that  the  latter  pro- 
cess caused  less  scale  and  less  corrosive  action  on  the  plates  of  steam 
boilers. 

"Slow  sand-filters  are  to  be  preferred  from  the  standpoint  of  op- 
eration. Slight  neglect  or  inattention,  or  mistaken  judgment  in  the 
management  of  the  filters,  cannot  at  once  seriously  damage  the  efflu- 
ent. Eapid  or  mechanical  filters  require  an  exact  proportionment  of 
coagulant  day  by  day.  and  sometimes  hour  by  hour  to  obtain  the  de- 
sired results.    While  such  careful  attention  can  sometimes  be  attained, 


Fig.  8. — Showing  Exact  Size  of  Filtering  Material  Used  in  Con- 
struction of  Sand  Filter.  (By  courtesy  of  tlie  Pittsburg  Filter  Manu- 
facturing Company.) 


pq 


be 


EXAMINATION  OF  WATER.  93 

it  nevertheless  must  be  admitted  that  the  simplicity  of  operation  of  the 
slow  sand-filters  is  a  decided  advantage. 

"We  therefore  are  of  the  opinion  that  slow  sand-filtration  as 
recommended  by  the  Commission  which  reported  to  Council  in  1899, 
is  most  suitable  because : — 

"1.  It  is  most  simple  and  durable. 

"2.  It  is  most  effective  imder  existing  circumstances. 

"3.  The  cost  of  construction  and  operation  is  reasonable,  and, 
according  to  careful  estimates,  no  greater  than  for  any  other  practic- 
able system." 

Similar  views  are  expressed  in  a  very  excellent  report  submitted 
by  Mr.  T.  A.  Leisen,  chief  engineer  of  the  Wilmington  Water  De- 
partment. 

Other  Methods  of  "Water  Purification. — Of  the  other  methods, 
the  use  of  ozone  is  the  only  one  deserving  consideration.  There  is 
no  doubt  that  ozone  destroys  the  bacteria  in  the  water  without  in  any 
way  changing  its  composition.  However,  the  method  is  still  in  the 
experimental  stage,  and  its  utility  on  a  large  scale  remains  to  be 
demonstrated. 


EXAMINATION  OF  WATER. 

The  average  consumer  judges  of  the  quality  of  the  drinking- 
water  by  means  of  his  special  senses  of  sight,  smell,  and  taste.  Water 
which  is  turbid  or  emits  a  disagreeable  odor  is  unreservedly  con- 
demned, while  clear,  sparkling  water  free  from  odor  is  just  as  un- 
qualifiedly pronounced  "pure."  Those  of  us  who  are  familiar  with 
the  history  of  typhoid  epidemics  and  have  had  opportunity  to  examine 
drinking-water  by  means  of  special  methods  know  how  fallacious 
such  a  crude  judgment  is.  Water  that  is  clear  and  sparkling  may 
contain  the  germs  of  typhoid  fever  or  may  be  polluted  with  sewage 
which,  in  the  course  of  decomposition,  gave  rise  to  carbonic  acid.  It 
takes  many  billions  of  bacteria  to  render  a  glass  of  water  perceptibly 
turbid,  and  it  requires  considerable  fresh  sewage  to  impart  to  it  a 
fecal  odor.  On  the  other  hand,  a  turbid  water,  although  objectionable 
from  an  esthetic  point  of  view,  may  be  entirely  wholesome,  and  a  dis- 
agreeable odor  may  be  due  to  inoffensive  vegetable  compounds  or 
harmless  algge. 

This  evident  inability  to  form  a  ready  judgment  of  the  quality 
of  a  drinking-water  has  led  the  sanitarian  to  seek  the  aid  of  the 
chemist,  who,   it  was  supposed,   could   readily   detect   by   means   of 


94  TEXT-BOOK  OF  HYGIENE. 

chemical  analysis  the  injurious  substances  in  the  water  under  sus- 
picion. However^  it  soon  became  evident  that  a  chemical  analj^sis  of 
water  for  sanitary  purposes  differs  essentially  from  any  other  kind  of 
analysis  which  the  chemist  may  be  called  upon  to  make.  The  find- 
ing of  arsenic  or  some  poisonous  alkaloid  in  a  suspected  fluid  is 
decisive,  and  a  report  on  such  finding  is  merely  a  statement  of  fact. 
In  the  analysis  of  water,  on  the  other  hand,  the  findings  are  purely 
relative  and  must  be  properly  interpreted  before  they  can  be  of  any 
value.  A  drinking-water,  to  use  the  legal  phraseology,  is  indicted 
on  circumstantial  evidence,  and  it  depends  on  the  erudition  and 
ability  of  the  chemist  to  so  interpret  and  connect  the  evidence  as 
to  make  out  a  clear  case  for  or  against  the  suspected  water. 

The  object  of  a  chemical  analysis  of  water  is  to  discover  wliether 
or  not  pollution  with  objectionable  organic  impurities  has  taken 
place.  By  "objectionable  organic  impurities"  we  understand  those 
which  are  from  human  or  animal  sources  and  are  capable  of  convey- 
ing the  germs  of  disease.  In  other  words,  we  look  principally  for 
fecal  contamination,  inasmuch  as  the  germs  of  tj'phoid  fever,  cholera, 
.dysentery,  and  other  intestinal  disorders  are  excreted  with  the  feces, 
and  together  with  the  feces  gain  access  to  the  water.  By  itself, 
organic  matter  in  the  minute  quantities  in  which  it  is  present  in 
water  is  not  injurious  to  health,  even  if  derived  from  sewage.  It  is 
only  because  this  organic  matter  may  be  the  carrier  of  disease  germs 
that  it  becomes  a  matter  for  serious  consideration.  Therefore,  organic 
matter  derived  from  plants  or  vegetables  removed  from  the  possi- 
bility of  infection  with  disease-producing  bacteria  has  no  significance 
from  a  sanitary  standpoint,  and  its  presence  in  drinking-water  in  no 
way  renders  it  unwholesome. 

It  is  thus  evident  that  the  aim  of  the  sanitary  chemist  is  to  dis- 
cover, first,  the  presence  of  organic  matter  which  would  indicate 
pollution,  and,  second,  to  determine  the  source  of  this  organic  matter. 
How  well  these  two  requirements  are  fulfilled  by  a  chemical  analysis 
will  be  made  clear  later. 

Dead  organic  matter  in  water,  as  elsewhere,  is  not  in  a  state  of 
stability.  Through  the  agency  of  certain  bacteria,  in  the  presence 
of  oxygen,  it  continuously  undergoes  material  changes,  becoming 
resolved  into  simpler  inorganic  compounds.  The  nitrogenous  sub- 
stances are  converted  into  ammonia,  and  the  latter  into  nitrous  and 
finally  nitric  acid,  the  two  acids  combining  with  bases  usually  present 
to  form  nitrites  and  nitrates,  respectively.  These  changes  may  be 
best  illustrated  by  the  following  scheme: — 


EXAMINATION  OF  WATER.  95 

{Carbon — Carbon  dioxide. 

Hydrogen        f.  .  [^^|^!\^  f^^  |  Nitric  acid 

XT-+  i  Ammonia  -{  (Nitrites)        >■  ,t.j-,      ,     , 

Nitrogen         \  \  Water  J  (^i^^'ates). 

This  process,  may  it  be  remarked  in  passing,  is  a  beneficial  one, 
since  by  its  means  purification  of  polluted  water  is  accomplished  and 
the  decaying  organic  matter  converted  into  useful  plant  food. 

These  changes,  under  favorable  conditions,  take  p^ace  incessantly 
so  long  as  there  is  a  supply  of  dead  organic  matter  and  the  neces- 
sary bacteria  are  present.  Therefore,  the  amount  of  organic  matter 
in  water  represents  that  portion  which  has  not  yet  undergone  disin- 
tegration— the  organic  nitrogen  or  so-called  albuminoid  ammonia — 
as  well  as  the  various  intermediary  products  of  the  portion  which 
has  undergone  or  is  undergoing  disintegration — free  ammonia, 
nitrites  and  nitrates.  The  quantitative  relation  of  these  products  of 
oxidation  to  each  other  as  well  as  to  the  unoxidized  nitrogenous 
matter  will  depend  on  the  original  amount  of  the  organic  matter  and 
the  rapidity  with  which  oxidation  has  taken  place.  Therefore,  an 
analysis  which  discloses  these  various  stages  of  oxidation  reveals 
also  not  only  the  presence  but  the  retrogressive  course  of  the  organic 
matter.  Given  a  water  containing  relatively  large  amounts  of  albu- 
minoid and  free  ammonia,  together  with  nitrites  and  nitrates,  the 
indications  would  be  that  such  water  contains  a  large  amount  of 
organic  matter  in  a  state  of  incomplete  oxidation;  in  other  words, 
the  contamination  is  recent.  On  the  other  hand,  the  presence  of 
nitrates,  in  the  absence  of  nitrites,  with  only  small  amounts  of  free 
and  albuminoid  ammonia,  would  indicate  complete  oxidation  or  a 
previous  pollution.  It  goes  without  saying  that  pure  water  should 
contain  only  traces  of  albuminoid  and  free  ammonia  and  should  be 
free  from  nitrites  and  nitrates,  the  latter,  if  in  small  quantity,  being 
rapidly  appropriated  by  the  water-plants.  It  is  to  be  expected  that  in 
deep  wells  removed  from  the  possibility  of  pollution,  the  water  will 
contain  very  slight  amounts  of  ammonia  and  no  nitrites  or  nitrates, 
or  mere  traces,  although  free  ammonia  may  sometimes  be  present 
in  large  amounts  as  a  result  of  oxidation  of  vegetable  matter  or 
nitrates  by  ferric  oxide. 

In  addition  to  organic  matter,  water  contains  various  salts,  the 
most  important  and  constant  of  which  is  sodium  chloride,  or,  occa- 
sionally, magnesium  and  calcium  chloride.  These  chlorides  are  de- 
rived from  the  sea  or  geological  formations  rich  in  salts.  The 
amount  of  chlorides  will  vary  witb  the  natural  source  and  remains 


96  TEXT-BOOK  OP  HYGIENE. 

fairly  constant.  However,  when  the  water  is  polluted  with  sewage 
or  household  refuse  the  chlorides  will  increase  in  proportion  to  the 
degree  and  nature  of  the  pollution,  and  this  increase  serves  as  a 
reliable  indication  of  past  or  present  pollution.  This  index,  how- 
ever, is  of  value  only  when  the  normal  chlorine  contents  of  the  water 
in  question  or  of  waters  in  the  immediate  neighborhood  are  known. 
There  are  a  number  of  serious  objections  to  the  data  obtained  by 
a  chemical  analysis,  (1)  Excessive  free  ammonia  in  ground-waters 
may  be  the  result,  as  has  been  mentioned,  of  the  oxidizing  action 
of  iron  or  other  metals  on  the  nitrates  present,  while  in  surface  waters 
it  may  be  produced  by  the  action  of  a  fungus  Crenothrix  (Brown). 
(2)  The  nitrites  found  in  deep-well  water  may  be  the  result  of  the 
reduction  of  nitrates  normally  present  in  the  soil  and,  consequently, 
in  no  way  represent  organic  pollution.  One  of  the  chief  objections, 
however,  is  that  a  chemical  analysis  does  not  reveal  the  nature  of  the 
organic  matter,  whether  of  vegetable  or  animal  origin.  Admitting 
that  a  certain  water  contains  an  excess  of  organic  matter,  the  ques- 
tion arises.  Does  this  organic  matter  represent  harmless  vegetables  or 
dangerous  sewage?  The  chemist  cannot  answer  this  question  with  a 
certainty  which  would  preclude  a  "reasonable  doubt.''  Yet  a  water 
contaminated  even  with  large  amounts  of  vegetable  matter,  while  not 
the  best  kind  of  water  to  drink,  is  nevertheless,  free  from  danger.  It 
is  true,  that  if  the  ammonia  on  distillation  is  given  off  rapidly  and 
the  nitrites  and  chlorine  are  excessive,  the  indications  that  the  organic 
matter  is  derived  from  sewage  are  reasonably  clear,  but  the  rapidity 
with  which  ammonia  even  from  the  animal  matter  is  given  off  is  only 
comparative  and  there  is  no  way  of  gauging  it,  while  a  correct  inter- 
pretation of  the  excessive  amount  of  chlorine  as  compared  with  the 
normal  chlorine  standard  of  that  particular  locality  presupposes  a 
previous  study  of  unpolluted  waters  which  is  seldom  made  and  which 
often  cannot  be  made. 

The  other  objection,  one  of  a  much  more  serious  nature,  is 
that  water  may  be  organically  pure  and  yet  contain  germs  of  disease. 
Instances  are  cited  by  a  number  of  authors  showing  that  water- 
supplies  pronounced  on  chemical  evidence  to  be  above  suspicion  have 
been  proved  to  have  caused  serious  epidemics  of  typhoid  fever  or 
dysentery.  Thus  Dr.  Thresh,  in  his  well-known  book  on  "Water  and 
Water-supplies,"  cites  a  number  of  such  instances. 

The  water  from  the  river  Ouse,  below  where  it  receives  the  sewage 
of  Buckingham,  to  which  an  epidemic  of  typhoid  fever  was  attrib- 


EXAMINATION  OF  WATER.  97 

uted,  was  analyzed  by  the  public  analyst,  who  reported  that  it  "does 
not  appear  from  the  analysis  to  contain  sewage  matter/' 

The  Beverly  water-supply,  which  became  polluted  with  infected 
sewage  from  an  asylum,  giving  rise  to  a  typhoid  epidemic,  was  pro- 
nounced by  the  chemist  to  be  "of  a  very  high  degree  of  purity,  and 
eminently  suitable  for  drinking  and  domestic  purposes." 

Analysis  of  water  from  the  sewage-polluted  Trent  showed  that 
"there  is  no  evidence  of  the  product  of  sewage  contamination." 

The  well-water  supplying  Houghton-le- Spring  became  contami- 
nated with  sewage  from  a  farm,  causing  a  sudden  outbreak  of  typhoid 
fever.  The  chemist  who  analyzed  the  water  reported  that  "this  water 
is  very  free  from  indications  of  organic  impurity.  .  .  .  It  is  a 
good  water  for  drinking  purposes." 

The  reason  for  this  evident  failure  on  the  part*  of  the  chemist  to 
detect  dangerous  pollution  is  not  difficult  to  find.  A  generally  pure 
water  may  become  contaminated  with  an  amount  of  sewage  too 
small  to  give  evidence  of  its  presence  when  diluted  with  several  mil- 
lion gallons  of  water,  yet  this  small  amount  of  sewage  may  contain 
numerous  specific  germs  the  presence  of  which  cannot  be  detected  by 
a  chemical  analysis.  Again,  the  sewage  may  have  undergone  com- 
plete oxidation  and  the  end-products  taken  up  by  the  plants,  leaving 
no  perceptible  evidence  of  the  pollution,  while  many  of  the  specific 
germs  which  have  been  present  in  the  original  sewage  remain  viable 
and  capable  of  causing  disease. 

However,  the  employment  of  chemical  analysis  for  comparing 
different  waters  in  the  same  locality  or  a  certain  water  at  different 
times  is  of  undoubted  value.  In  this  connection,  the  data  obtained 
by  a  chemical  analysis  are  both  accurate  and  valuable.  Also  in  the 
study  of  filtration,  especially  of  the  slow  sand  type,  chemical  analy- 
sis of  the  raw  water  and  effluent  made  from  time  to  time  furnishes 
valuable  evidence  of  the  efficiency  of  the  filter  in  removing  turbidity 
and  color,  and  bringing  about  the  nitrification  of  organic  matter 
which  is  the  essential  feature  of  this  process  of  water-purification. 

Bacteriological  Examination. — With  the  advent  of  bacteriology, 
and  especially  after  the  introductioii  of  Koch's  plate  method  of  iso- 
lation of  bacteria,  the  hopes  of  the  sanitarian  had  been  revived.  It 
was  supposed  that  at  last  we  have  a  method  by  means  of  which  we  may 
detect  the  specific  causes  of  disease  in  water,  and  thus  place  the  ex- 
amination of  water  on  the  same  certain  basis  as  the  detection  of 
poisons.  With  the  knowledge  that  typhoid  fever  is  usually  caused 
by  the  drinking-water  and  after  the  discovery  by  Koch  that  cholera  is 


98  TEXT-BOOK  OF  HYGIENE. 

of  similar  origin,  it  was  expected  tliat  the  typhoid  bacilli  and  the 
cholera  spirilla  could  be  detected  in  the  suspected  water.  Unfortu- 
nately, disappointment  followed  all  attempts  in  this  direction.  It 
soon  became  evident  that  while  a  certain  water  had  been  the  cause 
of  either  a  cholera  or  typhoid  epidemic,  as  established  by  all  evidence 
at  hand,  neither  the  cholera  spirillum  nor  the  typhoid  bacillus  could 
be  detected  in  such  waters.  The  cause  for  this  failure  was  found  in 
the  great  predominance  of  water  bacteria  which  overgrow  and  obscure 
the  few  specific  parasites,  rendering  their  discovery  impossible.  The 
effort  may  be  compared  to  looking  for  a  needle  in  a  haystack.  While 
not  entirely  abandoned,  the  search  for  specific  micro-organisms  has 
not  been  made  the  object  of  routine  examinations;  and  until  some 
satisfactory  method  is  devised  by  which  the  saproph3^tic  bacteria  may 
be  entirely  eliminated  and  the  number  of  the  specific  micro-organisms 
increased  so  as  to  have  them  present  in  very  small  quantities  of  the 
water,  the  bacteriologist  must  depend  upon  other  data  upon  which  a 
conclusion  as  to  the  quality  of  the  water  may  be  reasonably  based. 
It  was  thought  for  a  time  that  the  number  of  bacteria  in  the  water 
could  serve  as  an  index  of  pollution,  and  a  number  of  standards  of 
bacterial  purity  have  been  suggested  by  various  authors.  Thus,  Koch 
considers  100  bacteria  per  cubic  centimetre  as  the  safe  limit  for  drink- 
ing-water; Miquel  raises  the  standard  to  1000;  Crookshank  agrees 
with  this  standard,  while  Mace  and  Migula  claim  that  250  to  500 
bacteria  is  the  highest  limit  for  a  good  drinking-water.  These  or  any 
other  arbitrary  standards  based  on  mere  number  of  bacteria  are  as 
fallacious  as  the  "standards"  proposed  from  time  to  time  for  ammo- 
nias, nitrites,  nitrates,  etc.  The  number  of  bacteria  in  water  Avill 
vary  greatly  with  the  medium,  the  reaction  of  the  medium,  the  length 
of  time  the  colonies  are  allowed  to  develop,  dilution,  etc.  And  there- 
fore, number  alone,  while  indicating  the  presence  of  organic  matter, 
does  not  necessarily  show  that  the  water  contains  pathogenic  germs. 
This  fact  can  be  more  readily  ascertained  by  determining  the  num- 
ber of  bacteria  which  develop  on  bile-agar^®  at  body  temperature  and 
the  presence  or  absence  of  bacillus  coli. 

Dr.  De   Chaumont^^   classifies  water  under  the   four  heads   of 
Pure  and  Wholesome  Water,  Usable  Water,  Suspicious  Water,  and 

^^  The  bile-agar  medium  is  prepared  according  to  the  following  formula: — 

Agar    1-5  gms. 

Sodium  taurocholate    5     " 

Peptone 2.0    " 

Water  100     c.  c. 

This  is  prepared  as  xisual  and  1  per  cent,  lactose  added. 

"Parkes'  Hygiene,  vol.  i,  pp.  103-106. 


EXAMINATION  OF  WATER. 


99 


Impure  Water.     The  characters  of  these  waters  are  arranged  in  a 
series  of  tables,  the  essential  details  of  which  are  given  in  Table  XIV. 


Table  XIV. 


Pure 

Usable 

1 
Suspicious 

Impure 

Water. 

Water. 

Water. 

Water. 

CHEMICAIj 

Constituents. 

I. 

II. 

ni. 

IV. 

Parts  in  100,000. 

Parts  in  100,000. 

Parts  in  100,000. 

Parts  in  100,000. 

Chlorine  in  solution  . 

Under  1.4000 

Under  4.2857 

4-7 

Above  7.1428 

Solids           "  total     . 

"       7.1428 

"     42.8571 

43-71 

"     71.4285 

"                "  volatile 

"      1.4000 

"      4.2857 

4-7 

"      7.1428 

Ammonia,  free  or  sa- 

line     

"      0.0020 

"      0.0050 

0.0050-0.0100 

"      0.0100 

Ammonia,  albuminoid 

"       0.0050 

"      0.0100 

0.0100-0.0125 

"      0.0125 

Nitric  acid  in  nitrates 

"       0.0323 

"      0.5000 

0.5-1.0 

"      1  0000 

"          "  nitrites 

Nil. 

Nil. 

0.0500 

"      0.0500 

Nitrogen  in  nitrates    . 

"      0.0140- 

"      0.1129 

0.1243-0.2373 

"      0  2415 

Total  nitrogen  .     .     . 

"      0.0230 

"      0.1252 

0.1255-0.2465 

"      0.2601 

Oxygen  absorbed  by 

permanganate    and 

acid  within  half  an 

hour  at  140O  F.  .     . 

"      0.0250 

"      0.1000 

0.1000-0.1500 

"      0.1500 

Total  hardness  .     .     . 

"      8.5 

"    17.3 

Above  17.0 

"    28.5 

Permanent  hardness  . 

"      3.0 

"      5.7 

"      5.7 

"      8.7 

Phosphoric     acid     in 

phosphates     .     .     . 

Traces. 

Traces. 

Heavy  traces. 

Heavy  traces 

Sulphuric  acid  in  sul- 

phates     

" 

Under  3.000 

Above  3.000 

Above  4.2857 

Heavy  metals    .     .     . 

Nil. 

Traces. 

Traces. 

(  Any  except 
\       iron. 

Hydrogen  sulphide    . 

" 

Nil. 

Nil. 

Present. 

Alkaline  sulphides 

Physicat.  Chaeacters. 
No.    I.  Colorless,    or    bluish    tint; 
transparent,  sparkling,  and  well  aer- 
ated;    no   sediment   visible  to   naked 
eye;    no  smell;    taste  palatable. 

No.  II.  Colorless,  or  slightly  green- 
ish tint;  transparent,  sparkling,  and 
well  aerated ;  no  suspended  matter, 
or  else  easily  separated  by  coarse 
filtration  or  subsidence;  no  smell; 
taste  palatable. 

No.  III.  Yellow,  or  strong,  green 
color;  turbid;  suspended  matter  con- 
siderable; no  smell,  but  very  marked 
taste. 

No.  IV.  Color,  yellow  or  brown; 
turbid,  and  not  easily  purified  by 
coarse  filtration ;  large  amount  of 
susnfndf'd  matter;  very  marked  smell 
or  taste. 


Microscopical  Characters. 
No.    I.    Mineral   matter ;    vegetable 
forms  with  endochrome ;    large  animal 
forms,   no   organic  debris. 

No.  II.    Same  as  No.  I. 


No.  HI.  Vegetable  and  animal 
forms  more  or  less  pale  and  colorless; 
organic  deiris;  fibres  of  clothing,  or 
other  evidences  of  house-refuse. 

No.  IV.  Bacteria  of  any  kind; 
fungi ;  numerous  vegetable  and  ani- 
mal forms  of  low  types;  epithelia,  or 
other  animal  structures;  evidences  of 
sewage;    ova  of  parasites,  etc 


100  TEXT-BOOK  OF  HYGIENE. 

Methods  of  Water  Analysis.  —  Turbidity.  —  This  may  be  de- 
termined either  by  the  platinum  wire  method  or  by  comparison  of  the 
sample  with  known  quantities  of  silica  suspended  in  water.  The 
standard  of  turbidity  adopted  by  the  United  States  Geological  Survey 
is  "a  water  which  contains  100  parts  of  silica  per  million  in  such  a 
state  of  fineness  that  a  bright  platinum  wire  one  millimetre  in  diam- 
eter can  just  be  seen  when  the  centre  of  the  wire  is  100  millimetres 
below  the  surface  of  the  water^  and  the  eye  of  the  observer  is  1.2 
metres  above  the  wire.  The  observation  being  made  in  the  middle 
of  the  day,  in  the  open  air,  but  not  in  sun-light,  and  in  a  vessel  that 
the  sides  do  not  shut  out  the  light  so  as  to  influence  the  results.  The 
turbidity  of  such  water  shall  be  100."-°.  To  carry  out  this  method,  a 
wooden  rod  5  feet  long  and  1  inch  square  is  taken  and  a  small  plati- 
num wire  1  millimetre  in  diameter  inserted  about  1  inch  from  the 
end.  The  rod  is  then  graduated,  the  mark  of  100  being  placed  at  a 
distance  of  100  millimetres  from  the  centre  of  the  wire.  The  inter- 
mediary graduations  are  made  according  to  a  table  furnished  by  the 
United  States  Geological  Survey  (Circular  No.  8,  1902).  The  mark 
on  the  rod  at  which  the  platinum  wire  vanishes  is  the  turbidity  in 
parts  per  million.  The  silica  method,  which  is  much  more  convenient, 
consists  of  a  standard  suspension  of  one  gramme  of  dried  diatoma- 
ceous  earth  in  one  litre  of  distilled  water.  This  represents  a  turbidity 
of  1000  parts  per  million.  From  this  stock  suspension,  standards  for 
comparison  are  prepared  by  diluting  certain  quantities  with  distilled 
water.  Thus  1  c.  c.  diluted  with  100  c.  c.  of  water  equals  a  turbidity 
of  10  parts  per  million.  The  comparison  is  made  in  100  c.  c.  Nessler 
tubes  or  glass-stoppered  bottles. 

Significance. — Turbidity  is  objectionable  from  an  esthetic  stand- 
point, although  highly  turbid  water  may  be  entirely  wholesome,  and 
vice  versa.  However,  no  one  likes  to  drink  muddy  water,  and  for  this 
reason  turbidity  enters  as  an  important  factor  in  determining  the 
quality  of  a  given  water  or  in  deciding  upon  the  desirability  and 
methods  of  filtration. 

Color. — The  color  of  a  water  is  determined  by  comparing  100 
c.  c.  of  the  sample  with  an  equal  quantity  of  a  standard  prepared  from 
a  solution  containing  1.246  grams  of  potassium  platinic  chloride  per 
litre.    This  solution  has  a  color  of  500. 

Significance. — Color  in  water  has  the  same  significance  as  tur- 
bidity, and  unless  due  to   organic  or  inorganic  impurities  such   as 

-"Report  of  Committee  on  Standard  Methods  of  Water  Analysis,  Amer- 
ican Public  Health  Association,  1905. 


EXAMINATION  OF  WATER.  101 

sewage  or  dyes,  has  no  effect  on  the  quality  of  the  water  from  a  purely 
hygienic  standpoint. 

Odor. — The  odor  is  determined  by  violently  shaking  a  bottle  half 
full  of  the  sample  and  then  smelling  it.  The  odor  generated  by  heat- 
ing is  determined  as  follows :"  About  150  c.  c.  of  the  sample  are  poured 
ii^to  a  400  c.c.  beaker.  The  beaker  is  covered,  placed  on  a  hot  plate, 
and  heated  to  just  below  boiling.  The  beaker  is  then  shaken  and  the 
odor  detected  by  the  smell. 

Significance. — The  odor  of  water  may  indicate  its  source  as  well 
as  the  presence  of  sewage.  Objectionable  odors,  however,  may  be 
caused  by  certain  micro-organisms.  Thus,  a  "fisliy"  odor  is  caused 
by  Uroglena,  an  "aromatic"  or  "rose  geranium"  odor  by  Asterionella, 
and  a  "pig-pen"  odor  by  Anabena.  A  very  disagreeable  odor  is  caused 
also  by  Crenothrix. 

Total  Solids. — This  is  determined  by  evaporating  100  c.c.  of 
the  water  in  a  weighed  platinum  dish,  drying  the  residue  in  an  oven 
at  105°  C.  for  thirty  minutes,  and  then  weighing.  The  weight  of  the 
residue  in  milligrams  equals  parts  per  million. 

Organic  Nitrogen. — The  presence  and  amount  of  organic  nitro- 
gen in  a  given  water  are  determined  as  free  ammonia,  albuminoid  am- 
monia, nitrites,  and  nitrates.  These  substances  represent  the  various 
stages  of  decomposition  which  organic  nitrogen  undergoes  in  its 
transformation  from  a  complex  to  a  simple  compound. 

Free  Ammonia. — This  is  determined  by  distilling  500  c.  c.  of  the 
sample  in  a  flask  connected  with  a  condenser.  The  distillate  is  col- 
lected in  glass  cylinders  (INTessler  tubes)  and  a  small  amount  of 
ISTessler  reagent-^  added  and  the  distillate  compared  with  standards 
prepared  by  adding  definite  quantities  of  ammonium  chloride  to  pure 
water.  As  a  rule  150  c.  c.  of  the  first  distillate  contain  all  of  the 
free  ammonia. 

Albuminoid  Ammonia. — After  the  free  ammonia  is  distilled  off, 
the  distillation  is  interrupted  and  50  c.  c  of  an  alkaline  solution  of 
potassium  permanganate-^  added.  The  distillation  is  resumed  and 
carried  on  until  four  or  five  Nessler  tubes  are  collected.  The  distil- 
late in  each  tube  is  then  treated  as  above. 

Nitrites. — One  hundred  c.  c.  of  the  sample  are  decolorized,  if 

^  This  reagent  reacts  with  minute  quantities  of  ammonia.  It  is  made 
by  dissolvinfi:  .50  gnis.  of  potassium  iodide  in  water  and  adding  a  saturated 
solution  of  mercuric  chloride,  enough  to  produce  a  permanent  precipitate. 
400  f.  c.  of  a  .50-per-cent.  solution  of  potassium  hydrate  are  added,  and  the 
whole  dilutefl  to  one  litre. 

^^  This  is  prepared  by  dissolving  200  gms.  of  potassium  hydroxide  and  8 
gms.  of  potassium  permanganate  in  a  litre  of  distilled  water. 


102  TEXT-BOOK  OF  HYGIENE. 

necessary,  with  aluminum  hydrate  and  poured  into  a  100  c.  c.  Nessler 
tube.  To  this  are  added  1  c.  c.  of  sulphanilic  acid  solution  ( 8 
grammes  of  sulphanalic  acid  in  1000  c.  c.  of  dilute  acetic  acid,  specific 
gravity  l.O-i)  and  1  c.  c.  naphthylamine  solution  (5  grammes  of 
naphthylamine  in  1000  c.  c.  of  dilute  acetic  acid).  The  tube  is  cov- 
ered, allowed  to  stand  for  ten  minutes,  and  the  resulting  pink  color 
compared  with  standards  containing  definite  amounts  of  sodium 
nitrite  in  solution,  the  standards  having  been'  treated  in  the  same 
manner  as  the  sample. 

Nitrates. — Twenty  c.  c.  or  less  of  the  sample  are  evaporated  on 
a  water-bath  and  the  residue  treated  with  1  c.  c.  of  phenolsulphonic 
acid  (phenol,  30  grammes;  concentrated  sulphuric  acid,  370 
grammes) .  About  10  c.  c.  of  water  are  added  and  enough  ammonia 
to  render  the  liquid  alkaline.  The  liquid  is  then  transferred  to  a 
100  c.  c.  ISTessler  tube,  distilled  water  added  to  the  100  c.  c.  mark,  and 
the  yellow  color  matched  with  standards  containing  definite  amounts 
of  potassium  nitrate,  and  -treated  as  above. 

Significance. — With  the  exception  of  deep  waters,  which  may 
contain  large  amounts  of  nitrogen  as  free  ammonia  (due  to  reduction 
of  nitrates)  and  still  be  pure,  the  presence  of  excessive  quantities  of 
organic  nitrogen  indicates  pollution.  An  excess  of  free  ammonia 
(above  0.06  parts  per  million),  especially  if  nitrites  are  present, 
points  to  recent  pollution,  while  an  excess  of  nitrates  (above  .2  parts 
per  million  for  surface-waters  and  2  parts  per  million  for  ground- 
waters) points  to  past  pollution.  As  to  albuminoid  ammonia,  Wank- 
lyn  holds  that  if  the  water  contains  aKove  0.10  per  million  it  begins 
to  be  very  suspicious,  and  if  over  0.15  parts  per  million,  it  should  be 
condemned  absolutely.  This  standard  is  regarded  by  Mason  as  too 
rigorous. 

Oxygen  Consumed. — One  hundred  c.  c.  of  the  sample  are  meas- 
ured into  a  flask,  10  c.  c.  of  dilute  sulphuric  acid^"^  and  10  c.  c.  of 
solution  of  potassium  permanganate^*  added;  the  flask  is  then  placed 
in  a  bath  of  boiling  water  and  kept  there  for  exactly  thirty  minutes. 
At  the  end  of  that  period,  the  flask  is  removed,  10  c.  c.  of  ammonium 
oxalate  solution-^  added,  and  the  clear  fluid  titrated  Avith  the  stand- 
ard permanganate  solution  until  a  faint  but  distinct  color  is  obtained. 


^'  One  part  of  sulphuric  acid  to  3  parts  of  distilled  water. 

^*  This  standard  solution  contains  0.4  gm.  of  potassium  permanganate  in 
one  litre  of  distilled  water. 

^  This  solution  contains  0.888  gm.  of  ammonium  oxalate  in  one  litre. 
One  c.  c.  of  this  solution  should  neutralize  one  c.  c.  of  the  permanganate. 


EXAMINATION  OF  WATER.  103 

Each  cubic  centimetre  of  the  standard  permanganate  in  excess  of 
the  oxalate  solution  rejDresents  0.0001  gram  of  oxygen  consumed  by 
the  sample.     This,  multiplied  by  10,  equals  parts  per  million. 

Significance. — This  determination  indicates  the  presence  of  or- 
ganic carbon.  If  the  oxygen  required  is  high  and  the  ammonias  ex- 
cessive, the  indications  are  that  the  pollution  is  of  vegetable  origin; 
while  if  the  ammonias  are  high  and  the  oxygen  required  low,  the  pol- 
lution is  in  all  probability  animal  in  character. 

Chlorine. — Solutions  required:  1.  Standard  silver-nitrate  solu- 
tion. To  1  litre  of  pure  distilled  water  add  4.788  grammes  of  pure 
silver  nitrate  (AgNOj).  One  cubic  centimetre  of  this  solution  is 
equivalent  to  1  milligramme  of  chlorine.  2.  Potassium-chromate  solu- 
tion. A  10-per-cent.  solution  of  potassium  chromate  (KoCrO^)  in  dis- 
tilled water  free  from  chlorine. 

Process :  To  100  c.  c.  of  the  water  to  be  tested  add  a  few  drops 
of  the  potassium-chromate  solution,  and  then  run  in  the  silver-nitrate 
solution  from  a  graduated  burette,  adding  it  drop  by  drop  and  stirring 
the  water  continually  with  a  glass  rod.  Continue  until  a  faint  but 
permanent  orange-red  tint  has  been  produced,  showing  that  all  the 
chlorine  has  been  combined  with  the  silver,  the  persisting  reddish  tint 
being  due  to  silver  chromate.  The  number  of  cubic  centimetres  of 
silver-nitrate  solution  used  indicate  the  number  of  milligrammes  of 
chlorine  in  100  c.  c.  of  the  water,  or  the  parts  per  100,000 ;  this  multi- 
plied by  10  gives  the  number  of  milligrammes  of  chlorine  in  1  litre, 
or  parts  per  million.  If  the  water  contain  but  little  chlorine,  the  test 
will  be  more  accurate  if  250  c.  c.  of  the  water  be  first  evaporated  over 
a  water-bath  to  about  50  c.  c.  before  proceeding  as  above :  four  times 
the  result  will  then  give  the  number  of  milligrammes  of  chlorine  in 
1  litre.  Should  it  be  desired  to  express  the  proportion  in  terms  of 
sodium  chloride,  multiply  the  result,  obtained  as  above,  by  1.648;  or 
make  up  the  silver-nitrate  solution  by  adding  2.905  grammes  to  the 
litre,  each  cubic  centimetre  of  this  solution  being  then  equal  to  1  milli- 
gramme of  sodium  chloride. 

Significance. — Chlorine,  or  its  compounds,  when  present  in 
drinking-water,  indicates  generally  sewage  pollution.  It  is  true  that 
chlorine  may  be  in  excess  in  water,  and  the  latter,  nevertheless,  be 
entirely  free  from  sewage  or  urine,  but  this  occurs  only  where  there  is 
a  natural  deposit  of  chlorine  compound  in  the  soil  from  which  the  sup- 
ply is  drawn.  If  communication  with  the  sea  or  salt-deposits  is 
exclnclcd,  the  chlorine  may  be  assumed  to  be  due  to  the  inflow  of 
sewage. 


104  TEXT-BOOK  OF  HYGIENE. 

Hardness. — Solutions  required:  1.  Soap  solution.  Dissolve 
about  10  grammes  of  Castile  or  soft  soap  in  1  litre  of  weak  (35  per 
cent.)  alcohol.  3.  Standard  lime  solution.  Dissolve  1.11  grammes 
pure  calcium  chloride  in  1  litre  of  distilled  water.  One  cubic  centi- 
metre of  this  solution  is  equivalent  to  1  m.  g.  of  calcium  carbonate 
(CaCOg).  Process:  Firsts  find  how  much  of  the  soap  solution  is 
needed  to  make  a  lather  with  100  c.  c.  of  distilled  water,  as  follows : 
Place  the  water  in  a  flask  holding  about  250  c.  c.  and  run  in  the 
soap  solution  from  a  burette,  a  few  drops  at  a  time,  corking  and  shak- 
ing the  flask  well  after  each  addition.  The  lather  should  have  a  depth 
of  about  one-fourth  of  an  inch,  and  should  be  permanent  for  at  least 
five  minutes.  Then  standardize  the  soap  solution  by  diluting  5  c.  c. 
of  the  standard  lime  solution  to  100  c.  c.  with  distilled  water  and  find- 
ing how  many  cubic  centimetres  of  the  soap  solution  are  necessary  to 
make  a  permanent  lather  with  it.  This  quantity,  less  the  number  of 
cubic  centimetres  needed  to  make  a  lather  with  the  100  c.  c.  of  dis- 
tilled water,  represents  the  amount  of  soap  solution  that  will  neutral- 
ize 5  m.  g.  of  calcium  carbonate  or  its  equivalent.  Lastly,  determine 
in  the  same  way  the  number  of  cubic  centimetres  of  soap  solution 
necessary  to  make  a  permanent  lather  with  100  c.  c.  of  the  water  to  be 
examined;  subtract  the  quantity  necessary  for  100  c.  c.  distilled  water 
and  estimate  the  amount  of  calcium  carbonate  or  its  equivalents  pres- 
ent, as  follows :  For  example,  it  takes  2  c.  c.  of  soap  solution  to  make 
a  lather  with  the  distilled  water  and  12  c.  c.  with  the  diluted  lime 
solution.  Then,  12  —  2  =  10  c.  c.  =  5  m.  g.  calcium  carbonate,  and 
each  cubic  centimetre  of  the  soap  solution  =  0.5  c.  c.  of  the  standard 
lime  solution,  or  0.5  m.  g.  calcium  carl)onate.  Consequently,  if  100 
c.  c.  of  the  water  examined  require  17  c.  c.  of  soap  solution,  it  must 
contain  (17  —  2)  X  0.5  =  7.5  m.  g.  calcium  carbonate  or  its  equiva- 
lent, and  1  litre  of  the  water  contains  75  m.  g.  calcium  carbonate. 

Lead,  Copper,  and  Iron. — To  50  or  100  c.  c.  of  the  water  in  a 
white  porcelain  dish,  or  in  a  tall  glass  jar,  over  white  paper,  add  a 
few  drops  of  ammonium  sulphide, —  (NH^)2S.  A  dark  coloration 
or  precipitate  indicates  the  presence  of  either  lead,  copper,  or  iron,  due 
to  the  formation  of  the  respective  sulphide.  Then  add  a  few  drops  of 
hydrochloric  acid  (HCl).  If  the  color  disappear,  iron  only  is  pres- 
ent; if  it  persist,  lead  or  copper  is  present.  In  the  latter  case,  add 
a  few  drops  of  acetic  acid  and  about  1  c.  c.  of  a  strong  solution  of 
pure  potassium  cyanide.  If  the  color  disappear,  it  is  due  to  copper; 
if  it  remain,  lead  is  present.  If  lead  only  is  present  in  the  water,  the 
above  test  will  detect  ^/^p  grain  per  gallon,     The  above  test  may  be 


EXAMINATION  OP  WATER.  105 

corroborated  as  follows :  Partly  fill  two  test-tubes  with  the  original 
water;  to  one  add  a  little  potassium-chromate  solution;  an  opacity 
and  the  deepening  of  the  color  to  a  canary  yellow  indicates  lead.  To 
the  second  add  a  drop  of  dilute  hydrochloric  acid  and  a  few  drops  of 
potassium-ferrocyanide  solution;  a  blue  color  indicates  iron,  either 
ferrous  or  ferric ;  a  bronze  or  a  mahogany-red  color  indicates  copper. 
Quantitative  tests  for  the  above  metals  may  be  made  by  making 
standard  solutions  of  the  respective  elements,  treating  a  measured 
quantity  of  the  original  water  with  the  proper  reagejit,  as  indicated, 
and  comparing  the  color  produced  with  that  given  by  a  definite  quan- 
tity of  the  respective  standard  solution. 

Phosphates. — Solution  required,  ammonium  molybdate:  Dis- 
solve 10  grammes  of  molybdic  anhydride  in  41.7  c.  c,  of  ammonia 
(NH^HO), — sp.  gr.  0.96, — and  pour  slowly  into  125  c.  c.  of  nitric 
acid  (HISrOg), — sp.  gr.  1.20;  allow  to  stand  in  a  warm  place  for  sev- 
eral days  till  clear.  Process :  slightly  acidify  500  c.  c.  of  the  water 
with  nitric  acid,  evaporate  to  about  50  c.  c,  add  a  few  drops  of  ferric 
chloride  (FcaClo)  and  ammonia  in  slight  excess.  Filter,  dissolve  the 
precipitate  in  the  smallest  possible  quantity  of  nitric  acid,  and  evap- 
orate to  5  c.  c.  Heat  nearly  to  boiling ;  add  2  c.  c.  of  ammonium- 
molj^bdate  solution;  keep  solution  warm  for  one-half  hour.  If  there 
is  an  appreciable  quantity  of  precipitate,  collect  it  on  a  small,  weighed 
filter-paper,  wash  with  distilled  water,  dry  at  100°  F.,  and  weigh. 
The  weight  of  the  precipitate  multiplied  by  0.05  gives  the  amount 
of  phosphates  as  PO4  in  the  500  c.  c.  of  water. 

Bacteriological  Examination. — The  following  method  of  proced- 
ure has  been  recommended  by  the  committee  on  laboratory  methods 
of  the  American  Public  Health  Association: — 

Media. — The  standard  medium  for  determining  the  number  of 
bacteria  in  water  shall  be  nutrient  gelatin,  and  for  polluted  waters 
which  cannot  be  plated  promptly  after  collection  agar  may  be  substi- 
tuted. All  variations  from  these  two  media  shall  be  considered  as 
special  media.  If  any  medium  other  than  standard  gelatin  is  used, 
this  fact  shall  be  stated  in  the  report.  For  general  work  the  standard 
reaction  shall  be  1  per  cent,  acid,  but  for  long-continued  work  upon 
water  from  the  same  source  the  optimum  reaction  shall  be  ascertained 
by  experiment  and  thereafter  adhered  to.  If  the  reaction  used,  how- 
ever, is  different  from  the  stanclard,  it  shall  be  so  stated  in  the  report. 

Procedure.— Shake  at  least  twenty-five  times  the  bottle  which 
contains  the  sample.  Withdraw  1  e.  c.  of  the  sample  with  a  sterilized 
pipette  and  deliver  it  into  a  sterilized  Petri  dish  10  centimetres  in 


106  TEXT-BOOK  OF  HYGIENE. 

diameter.  If  there  is  reason  to  suspect  that  the  number  of  bacteria  is 
more  than  200  per  cubic  centimetre,  mix  1  c.  c.  of  the  sample  with 
9  c.  c.  of  sterilized  tap  or  distilled  water,  and  so  on.  Shake  twenty- 
five  times  and  measure  1  c.  c.  of  the  diluted  sample  to  a  Petri  dish. 
If  a  higher  dilution  is  required,  proceed  in  the  same  manner,  e.g., 
1  c.  c.  of  the  sample  to  99  c.  c.  of  sterilized  water,  or  1  c.  c.  of  the  once 
diluted  sample  to  99  c.  c.  of  sterilized  water,  and  so  on.  In  the  case 
of  an  unknown  water  it  is  advisable  to  use  several  different  dilutions 
for  the  same  sample.  To  the  liquid  in  the  Petri  dish  add  10  c.  c.  of 
standard  gelatin  at  a  temperature  of  about  30°  C,  or  10  c.  c.  standard 
agar  at  a  temperature  of  about  40°  C.  Mix  the  medium  and  water 
thoroughly  by  tipping  the  dish  back  and  forth,  and  spread  the  con- 
tents equally  over  the  bottom  of  the  plate.  Allow  the  gelatin  to  cool 
rapidly  on  a  horizontal  surface  and  transfer  to  the  20°  C.  incubator 
as  soon  as  it  is  hard.  Incubate  the  culture  for  forty-eight  hours  at  a 
temperature  of  20°C.  in  a  dark,  well-ventilated  incubator  where  the 
atmosphere  is  practically  saturated  with  moisture.  After  this  period 
of  incubation  place  the  Petri  dish  on  a  glass  plate  suitably  ruled,  and 
count  the  colonies  with  the  aid  of  a  lens  which  magnifies  at  least  five 
diameters.  So  far  as  practicable,  the  number  of  colonies  upon  the 
plate  shall  not  be  allowed  to  exceed  200.  The  whole  number  of  col- 
onies upon  the  plate  shall  be  counted,  the  practice  of  counting  a 
fractional  part  being  resorted  to  only  in  case  of  necessity. 

When  agar  is  used  for  plating,  it  will  be  found  advantageous  to 
use  Petri  dishes  with  porous  earthenware  covers  in  order  to  avoid 
the  spreading  of  colonies  by  the  water  of  condensation. 

For  the  detection  of  B.  coll  and  other  specific  bacteria  consult 
text-book  on  bacteriology. 


QUESTIONS  TO  CHAPTER  II. 

WATER. 

For  what  purposes  do  people  need  water?  Why  should  the  supply  be 
pure?  What  is  the  quantity  needed  by  each  person  daily,  and  what  quantity 
should  be  supplied  per  head  in  towns  and  cities  for  all  purposes?  How  may 
waste  of  water  be  prevented?  What  is  the  objection  to  the  use  of  water- 
meters  ? 

What  is  the  original  source  of  all  fresh  water?  How  is  rain-water  usually 
collected  and  stored?  What  are  the  objections  to  underground  cisterns?  What 
is  the  only  material  of  which  underground  cisterns  should  be  made? 

From  what  source  do  most  cities  and  towns  derive  their  water-supply? 
What  precautions  must  be  observed  regarding  such  a  source?  What  arc  some 
of  the  minor  objections  to  the  use  of  river-water?  What  peculiar  diseases 
may  be  due  to  such  water?  What  is  the  most  serious  objection  to  the  use 
of  river-water  for  domestic  purposes? 

How  does  a  running  stream  purify  itself?  Can  this  self -purification  be 
relied  upon?  Can  it  be  stated  definitely  when  a  stream  once  polluted  becomes 
fit  for  use  again?  Is  it  safe  to  use  water  from  a  stream  known  to  have  been 
contaminated  by  sewage? 

What  is  usually  the  quality  of  water  from  fresh-water  lakes  and  ponds? 
What  large  city  uses  lake- water  entirely?  What  precautions  must  be  observed 
regarding  such  a  source  of  supply?  To  what  is  the  off'ensive  taste  and  odor 
of  water  from  small  lakes  or  storage-reservoirs  often  due? 

Does  water  purify  itself  absolutely  in  freezing?  What  matters  may  be 
found  in  ice?  Are  all  pathogenic  micro-organisms  destroyed  by  freezing? 
What  part  of  ice  is  the  purest  ? 

What  class  of  peisons  usually  derive  their  drinking-water  from  springs 
and  wells?  What  is  the  relative  purity  of  spring-  and  of  well-water?  Why? 
What  changes  take  place  in  diluted  organic  matter  in  percolating  through  the 
soil?  To  what  are  these  changes  due?  What  may  retard  or  check  these 
changes?  Is  water  containing  nitrites  and  nitrates  necessarily  dangerous?  Of 
what  are  nitrites  and  nitrates  an  indication? 

Name  some  of  the  qualities  that  are  desirable  in  water  for  drinking  or 
domestic  purposes.     When  is  a  water  said  to  be  hard? 

To  what  is  the  hardness  of  water  due?  What  is  the  distinction  between 
"removable"  or  "temporary"  and  "permanent"  hardness,  and  what  is  meant 
by  "total"  hardness?  How  is  the  degree  of  hardness  determined,  and  upon 
what  does  the  test  depend?  Describe  the  test.  Why  is  hard  water  objection- 
able for  domestic  use? 

(107) 


108  TEXT-BOOK  OF  HYGIENE. 

What  diseases  and  derangements  of  health  maj'  be  due  to  hard  water? 
Is  the  evidence  absolute  regarding  all  of  these?  What  troubles  may  large 
amounts  of  suspended  mineral  matter  cause?  How  may  such  water  be  clari- 
fied?    What  mineral  in  the  water  is  essential  to  the  process? 

What  may  be  the  effect  of  large  quantities  of  organic  matter  in  the 
water?  What  infectious  diseases  may  be  due  to  impure  drinking-water?  What 
other  organisms  hannful  to  health,  other  than  bacteria,  may  be  found  in  drink- 
ing-water? Name  some  notable  places  where  epidemics  have  been  undoubt- 
edly caused  by  impure  drinking-water.  How  may  a  milk-supply  be  infected 
by  impure  water?  How  might  a  water  be  polluted  in  distribution,  even  though 
the  source  be  pure? 

What  is  the  advantage  of  a  prolonged  storage  of  river-water?  What 
waters  should  not  be  stored  in  lead-lined  cisterns  or  conveyed  in  leaden  pipes? 
What  is  the  greatest  amount  of  lead  permissible  in  water? 

In  what  ways  may  water  be  purified  on  a  large  scale  ?  Explain  the  process 
of  sand  filtration. 

Wliat  methods  may  be  used  in  the  household  for  the  purification  of 
water?  How  may  the  water  be  softened?  How  may  disease  germs  and  other 
organisms  in  water  be  destroyed?  How  may  organic  matter  be  removed? 
What  are  some  good  filtering  materials?  ^^^lat  are  some  of  the  essential 
requisites  of  a  good  house-filter?  What  is  necessary  that  every  house-filter 
may  be  safe  for  use?    Are  any  filters  absolutely  germ-proof? 

How  are  the  color,  transparency,  and  odor  of  water  determined,  and 
what  is  the  standard  of  comparison?  Is  a  turbid  or  colored  water  necessarily 
harmful,  and  may  a  perfectly-clear  water  be  dangerous  to  use? 

How  are  the  total  solids  of  a  water  determined  quantitatively?  Describe 
the  permanganate-of-potash  test  for  the  deteniiination  of  the  organic  matter 
in  water.  What  does  an  excess  of  chlorine  or  chlorides  in  water  generally 
indicate,  and  why?  How  may  these  be  determined  quantitatively?  If  sewage 
contamination  of  a  water  be  suspected,  how  may  the  suspicion  be  confirmed? 
Why  should  the  presence  of  nitrites  or  nitrates  in  water  excite  the  suspicion 
of  sewage  contamination.  Give  a  test  fOr  each.  By  what  reagent  is  the 
presence  of  ammonia  determined? 

How  may  we  know  whether  an  excess  of  chloi'ides  is  due  to  sewage  con- 
tamination or  not?  What  is  the  probable  source  of  ammonia  if  in  excess  and 
in  company  with  nitrates,  etc.  ?  Which  is  supposed  to  indicate  the  most  recent 
contamination,  nitrites  or  nitrates?  What  does  the  presence  of  nitrates  with- 
out nitrites  or  ammonia  indicate?  What  lime-salt  is  most  readily  removed  by 
boiling? 

What  relation  has  the  organic  matter  to  the  nitric  acid? 

Into  what  four  classes  may  water  be  divided?  Name  some  of  the  char- 
acteristics of  these  different  classes. 

What  are  the  solutions  needed  in  the  quantitative  test  for  chlorine? 
What  is  the  strength  of  each,  and  what  is  the  relation  of  the  silver-nitrate 
solution  to  chlorine?     What  is  the  use  of  the  potassium-chromate  solution? 


QUESTIONS  TO  CHAPTER  II.  109 

How  may  the  result  be  expressed?     What  solutions  are  used  in  testing  for 
nitrates  quantitatively? 

In  testing  for  hardness,  why  is  a  standard  lime  solution  necessary  ?  Wliat 
should  be  the  characteristics  of  the  lather  produced  by  the  soap  solution? 
Why  is  alcohol  used  as  a  solvent  for  the  soap?  What  is  the  underlying  prin- 
ciple of  this  test? 

How  may  lead,  copper,  or  iron  be  detected  in  water?  How  may  you 
distinguish  between  the  respective  sulphides  of  the  above  metals?  How  may 
the  above  test  respecting  any  one  of  the  metals  be  corroborated?  How  deli- 
cate is  the  test,  as  regards  lead?  How  might  a  quantitative  determination  of 
these  metals  be  made?  What  is  the  principal  reagent  used  in  the  test  for 
phosphates? 

How  may  a  bacteriological  examination  of  water  be  made?  What  pre- 
cautions must  always  be  observed  in  such  examinations? 


CHAPTER  III. 

FOOD. 

In  order  to  preserve  health  and  vigor  it  is  necessary  for  animal 
beings  to  consume  at  intervals  a  sufficient  quantity  of  substances 
known  as  food.  Alimentary  substances,  or  foods,  may,  therefore,  be 
briefly  defined  as  materials  which,  taken  into  the  body  and  assim- 
ilated, sustain  the  processes  of  life,  promote  growth,  or  prevent  de- 
struction of  the  organized  constituents  of  the  body. 

According  to  Atwater,^  a  food  is  a  "material  which,  when  taken 
into  the  body,  serves  to  either  form  tissue  or  yield  energy,  or  both." 
This  definition  includes  all  the  ordinary  food-materials,  since  they 
build  tissue  as  well  as  yield  energy ;  but  it  excludes  creatin,  creatinin, 
and  other  so-called  meat-extractives  and  likewise  thein  or  caffein 
of  tea  and  coffee,  as  they  neither  build  tissue  nor  yield  energy. 

QUANTITY   AND   CHARACTER   OF   FOOD   NECESSARY. 

It  has  long  been  known,  as  the  result  of  the  empirical  observa- 
tion of  feeding  large  bodies  of  people,  that  the  various  proximate 
principles  composing  the  tissues  must  be  combined  in  certain  definite 
proportions  in  the  food  in  order  to  preserve  the  normal  degree  of 
health  and  vigor  of  the  body.  Within  a  comparatively  recent  period 
physiologists  have  made  experiments  upon  animals  and  liuman  beings 
which  have  led  to  the  same  conclusions,  and  have  enabled  these  pro- 
portions to  be  fixed  with  more  or  less  exactness. 

Considering  man  as  an  omniverous  animal,  it  may  be  laid  down 
as  an  invariable  rule  that  the  following  four  alimentary  principles 
are  necessary  to  his  existence.^  ISTeither  of  these  principles  can  be 
dispensed  with  for  a  prolonged  period  without  illness  or  death  re- 
sulting. 

1.  Water. — This  must  be  supplied  in  sufficient  quantity  to  permit 
the  interchange  of  tissue  to  be  carried  on  in  the  body. 

2.  Salts. — Inorganic  compounds  of  various  kinds  are  necessary 
to  the  preservation  and  proper  construction  of  the  tissues.  They  are 
all  found  in  sufficient  quantities  in  the  various  alimentary  substances 


^U.  S.  Department  of  Agriculture,  Bui.  No.  21. 
^  Physiologie,  Landois,  2te  Aufl.,  p.  448. 

(110) 


QUANTITY  AND  CHARACTER  OF  FOOD  NECESSARY. 


Ill 


consumed  by  man  and  the  lower  animals.     A  deficiency  of  inorganic 
constituents  in  the  food  is  followed  by  disease, 

3.  Proteids. — Organic  nitrogenous  material,  either  animal  or 
vegetable,  is  a  necessary  constituent  of  the  food  of  man.  Continued 
existence  is  impossible  without  a  sufficient  supply  of  nitrogenous 
substances. 

4.  Fats  or  Carbohydrates. — The  organic  non-nitrogenous  or  car- 
bonaceous principles  of  food  are  also  necessary  to  the  continuance  of 
health.  They  are  supplied  either  by  fats  or  by  carbohydrates  (sugar, 
starch,  etc.),  which  may,  within  certain  limits,  be  used  as  substitutes 
for  each  other.  Voit  has  shown  that  17  parts  by  weight,  of  starch, 
are  equivalent  as  carbonaceous  or  oxidizable  food  to  10  parts  of  fat. 

The  physiology  of  nutrition  has  been  very  carefully  studied  by 
a  large  number  of  experimental  physiologists,  who  have  arrived  at 
conclusions  differing  widely  from  those  generally  accepted  by  the 
older  writers  on  the  subject.  The  division  of  foods  into  plastic  and 
respiratory  foods,  or,  in  a  general  way,  into  proteids,  or  muscle- 
builders,  and  fats  and  carbohydrates,  or  oxidizing  foods,  is  now  no 
longer  recognized  in  science.  It  has  been  established  that  proteid  tis- 
sues are  not  alone  the  result  of  proteid  food,  and  that  the  accumula- 
tion of  fat  in  the  body  is  not  altogether  due  to  the  excessive  con- 
sumption of  fats  and  carbohydrates.  It  has  been  further  shown,  con- 
trary to  the  general  belief,  that  the  nitrogenous  or  proteid  tissues  are 
not  used  up  during  hard  labor  any  faster  than  when  at  perfect  rest, 
but  that,  on  the  contrary,  increased  muscular  exertion  is  attended  by 
increased  consumption  of  stored-up  fat. 

These  facts  have  led  to  a  modification  of  the  standard  dietaries 
formerly  employed.  At  present  the  standards  of  the  quantity  of  food 
principles  required  to  maintain  equality  between  bodily  income  and 
expenditure  are  those  calculated  by  Professor  Yoit,  and  Professor 
Atwater  in  this  country,  after  many  experiments  upon  human  beings 
and  the  lower  animals.     These  standards  are  as  follow: — 


.     Table  XV. 

ADULT  MALE  OF  AVERAGE  WEIGHT. 


At  Rest. 

Moderate  Labor. 

Severe  Labor. 

Proteids      .... 
Fats 

Carbohydrates     .     . 

110  grammes 

50       " 
450       " 

118  grammes 
50       " 
500       " 

145  grammes 

100       " 
500       " 

112 


TEXT-BOOK  OF  HYGIENE. 


Table  XVI. 

Comparative  Cost  of  Digestible  Nutrients  and  Energy  in  Different  Food  Materials 

of  Average  Prices.^ 

[It  is  estimated  that  a  man  at  light  to  moderate  muscular  work  requires  ahout  0.23  pounds  of 

protein  and  3,050  calories  of  energy  per  day.] 


Kind  of  Food  Material 


Beef,  sirloin 

Beef,  sirloin 

Beef,  sirloin 

Beef,  round 

Beef,  round 

Beef,  round 

Beef,  shoulder  clod  ..... 

Beef,  shoulder  clod 

Beef,  stew  meat  ....... 

Beet,  dried,  chipped 

Mutton  Chops,  loin 

Mutton,  leg 

Mutton,   leg      

Roast  pork,  loin 

Pork,  smoked  ham 

Pork,  smoked  ham 

Pork,  fat  salt 

Codfish,  dressed,  fresh  .... 

Halibut,  fresh 

Cod,  salt     

Mackerel,  salt,  dressed    .   .   . 

Salmon,  canned 

Oysters,  solids,  50  cts.  per  qt. 
Oysters,  solids,  35  cts.  per  qt. 

Lobster,  canned 

Butter      

Butter      

Butter 

Eggs,  36  cents  per  dozen  .  .  . 
Eggs,  24  cents  per  dozen  .  .  . 
Eggs,  12  cents  per  dozen  .  . 

Cheese  .....       

Milk,  7  cents  per  quart .  .  .  . 
Milk,  6  cents  per  quart .  .  .   . 

Wheat  flour 

Wheat  flour 

Corn  meal,  granular  .  .  .  . 
Wheat  breakfast  food  .... 

Oat  breakfast  food 

Oatmeal 

Rice      

Wheat  bread 

Wheat  bread 

Wheat  breai 

Rye  bread 

Beans,  white,  dried 

Cabbage  

Celery 

Corn,   canned 

Potatoes,  90  cents  per  bushel  . 
Potatoes,  60  cents  per  bushel  . 
Potatoes,  45  cents  per  bushel  . 

Turnips 

Apples 

Bananas  

Oranges       ....  .   .   .   . 

Strawberries 

Sugar 


Cents 

25 

20 

15 

16 

14 

12 

12 

9 

5 
25 
16 
20 
16 
12 
22 
18 
12 
10 
18 

7 
10 
12 
25 
18 
18 
20 
25 
30 
24 
16 

8 
16 

3^ 

3 

8 
6 
5 
4 
5 
5 

5 
10 

1 

v^ 

6 
7 
6 


"  a 
■"0.5 
o  a  <c 


Dollars 

1.60 

1.28 

.96 

.87 

.76 

.65 

.75 

.57 

.35 

.98 

1.22 

1.37 

1.10 

.92 

1  60 

1.30 

6.67 

.93 

1.22 

.45 

.74 

.57 

4  30 

3.10 

1.02 

20.00 

25.00 

30.00 

2.09 

1.39 

.70 

.64 

L09 

.94 

.31 

.26 

.32 

.73 

.53 

.29 

1.18 

.77 

.64 

.51 

.65 

.29 

2.08 

6.65 

4.21 

1.00 

.67 

.50 

1.33 

5.00 

10.00 

12.00 

8.75 


oO  BO 


oSw 


Cents 

25 

20 

15 

18 

16 

13 

17 

13 
7 

32 

11 

22 

18 

10 

13 

11 
3 

46 

88 

22 
9 

13 
111 

80 

46 
6 
7 
9 

39 

26 

13 
8 

11 

10 
2 
2 
2 
4 
4 
2 
5 
5 
4 
3 
4 
3 

22 

77 

23 
5 
3 
3 


^  box)  a> 


Amounts  foe  10  Cents 


Pounds 

0,40 

.50 

.67 

.63 

.71 

.83 

.83 

1.11 

2 

.40 

.63 

.50 

.63 

.83 

.45 

.56 

.83 

1 

.56 

1.43 

1 

.83 

.40 

.56 

.56 

.50 

.40 

.33 

.42 

.63 

1.25 

.63 

2.85 

3.33 

3.33 

4 

4 

1.33 
1.33 
2.50 
1,25 
1.67 
2 

2.50 
2 
2 
4 
2 
1 

6.  7 
10 

13.33 
10 
6.67 
1.43 
1.67 
1.43 
1,67 


Pound 
0.06 
.08 
.10 
.11 
.13 
.15 
.13 
.18 
.29 
.10 
.08 
.07 
.09 
.11 
.06 
.08 
.02 
.11 
.08 
.22 
!]3 
.18 
.02 
.03 
.10 
.01 


.05 
.07 
.14 
.16 
.09 
.11 
.32 
.39 
.31 
.13 
il9 
.34 
.08 
.13 
.16 
.20 
.15 
.35 
.05 

M 

.02 
.10 
.15 
.20 
.08 
.02 
.01 
.01 
.01 


Pound 
0.06 
.08 
.11 
.08 
.09 
.10 
.08 
.10 
.23 
.03 
.17 
.07 
.09 
.19 
.14 
.18 
.68 

",02 
.01 
.20 
.10 

','oi' 

.01 
.40 
.32 
.27 
.04 
,06 
.11 
.20 
.11 
.13 
.03 
04 
.07 
.02 
.09 
.16 

'.02 
.02 
.03 
.01 
.03 
.01 

VoV 

.01 
.01 
.01 
.01 
.02 
.01 


W 


Pounds 


.01 
.02 


.02 

.14 

.17 

2  45 

2.94 

2  96 

.98 

.86 

1.66 

.97 

.87 

1.04 

1.30 

104 

1.16 

.18 

.05 

.18 

.93 

1.40 

1  87 

.54 

.65 

.18 

.13 

.00 

1.67 


Calories 

410 

515 

685 

560 

630 

740 

595 

795 
1,530 

315 

890 

445 

560 
1,035 

735 

915 
2,950 

230 

262 

465 
1,135 

760 
90 

125 

225 
1,705 
1,365 
1,125 

260 

385 

770 
1,185 

885  ■ 
1  030 
5,440 
6,540 
6,540 
2,235 
2,395 
4,500 
2.025 
2,000 
2,400 
3,000 
2,340 
3,040 

46') 

130 

430 
1,970 
2,950 
3,935 
1,200 
1,270 

370 

250 

215 
2,920 


sPrinciples  of  Nutiition  and  Nutritive  Value  of  I'ood.  By  W.  0.  Atwater.  U.  S.  Dept. 
Agr.    Bull.  Ko.  142. 

^The  cost  of  1  pound  of  protein  means  the  cost  of  enough  of  the  given  material  to  furnish 
1  pound  of  protein,  without  regard  to  the  amounts  of  the  other  nutrients  present.  Likewise  the 
cdst  of  energy  means  the  cost  of  enough  material  to  furnish  1,000  calories  without  reference  to  the 
kinds  and  proportions  of  nutrients  in  which  the  energy  is  supplied.  These  estimates  of  the  cost 
of  protein  and  energy  are  thus  incorrect  in  that  neither  give^  credit  for  the  value  of  the  other. 


QUANTITY  AND  CHARACTER  OF  FOOD  NECESSARY.  113 

As  the  average  weight  of  women  is  less  than  that  of  men,  a  re- 
duction of  from  15  to  20  per  cent,  in  the  various  food  principles  may 
be  made  for  the  female  ration. 

The  relative  proportion  of  nitrogenous  to  non-nitrogenous  prin- 
ciples in  this  ration  is  about  1  to  5.  In  the  older  diet  standards,  e.g., 
Moleschott's,  the  proportion  of  nitrogenous  to  non-nitrogenous  prin- 
ciples is  much  larger,  being,  for  a  man  at  moderate  labor,  proteids, 
130  grammes;  fats,  84  grammes;  and  carbohydrates,  404  grammes, 
or  about  1  to  3.75. 

While  from  ignorance,  or  motives  of  economy,  many  men  sustain 
life  and  preserve  health  at  hard  labor  on  rations  varying  considerably 
from  the  standard  above  given,  it  is  probable  that,  all  things  being 
considered,  the  most  perfect  physiological  ration  would  also  be  the 
most  economical.  Thus,  Professor  Vaughn  proposes  a  daily  ration 
consisting  of  bread,  cod-fish,  lard,  potatoes,  bacon,  beans,  milk,  sugar, 
and  tea  in  such  proportions  as  to  furnish  123  grammes  proteids,  70 
grammes  fats,  and  550  grammes  carbohydrates.  The  total  cost  or 
money  value  of  this  ration  at  present  prices  is  about  thirteen  cents. 
In  actual  food  value  it  is  not  inferior  to  the  daily  fare  of  the  habitue 
of  Delmonico's.     (See  Table  XVI.) 

In  estimating  the  food  requirements  of  the  organism,  account 
is  taken  of  the  fact  that  the  body  takes  in  potential  energy  in  the 
form  of  food  and  generates  kinetic  energy  in  the  form  of  heat  and 
motion. 

"Heat  and  muscular  power  are  forms  of  force  or  energy.  The 
energy  latent  in  the  food  is  developed  as  the  food  is  consumed  in  the 
body.  The  process  is  more  or  less  akin  to  that  which  takes  place  when 
coal  is  burned  in  the  furnace  of  the  locomotive.  For  the  burning  of 
the  food  in  the  body  or  the  coal  in  the  furnace,  air  is  used  to  supply 
oxygen.  When  the  fuel  is  oxidized,  be  it  meat  or  wood,  bread  or  coal, 
the  latent  energy  becomes  active,  or,  in  technical  language,  the  poten- 
tial energy  becomes  kinetic;  it  is  transformed  into  heat  and  power. 
As  various  kinds  of  coal  differ  in  the  amount  of  heat  given  off  per  ton, 
so  various  kinds  of  food  and  food  ingredients  give  off  different 
amounts  of  energy;  that  is,  have  different  values  as  fuel  in  the  body."° 

The  unit  of  measurement  of  the  fuel-valve  of  food  is  a  calorie, 
which  is  the  amount  of  heat  required  to  warm  one  gramme  of  water 
one  degree  centigrade.  One  calorie  is  equal  to  about  1.54  foot-tons; 
in  other  words,  one  calorie,  when  transformed  into  mechanical  power, 
would  lift  one  ton  1.54  feet. 


"Atwater.     U.  S.  Department  of  Agriculture,  Bull.  No.   142. 


114 


TEXT-BOOK  OF  HYGIENE. 


Table  XVII. 

Standard  Dietaries  {Hutchison). 
For  a  man  at  moderate  muscular  work. 


Food  Materials 

Amount 

Proteids 

Fats 

Carbo- 
hydrates 

Fuel  Value 

I. 
Beef,  round  steak 

Ounces 

13 
3  . 

6 
22     • 

Pounds 
0.14 

6.02 
0  12 

Pounds 

0.12 
0.16 

6.02 

Pounds 

6^15' 
0.75 

Calories 

695 

Batter 

680 

Potatoes 

320 

Bread  

1760. 

44 

0.28 

0.30 

0.90 

3455 

II. 

Pork,  salt 

4 

2 

16 

8 

6^23 
0.04 

0.21 
0.11 
0.02 
0.01 

'  6.59 ' 
0.28 

880    - 

Butter 

450 

Beans 

1615 

IBread 

640 

30 

0.27 

0.35 

0  87 

3585 

III. 
Beef,  neck 

16 
16 

4 
16 

3 

0.10 

'  \)M ' 
0.02 
0.04 
0.09 

0.09 
0  05 
0.04 

'6.02' 
0.02 

0.05 
0.15 
0.17 
0.56 
0.19 

550 

Butter 

225 

Milk,  one  pint 

325 

Potatoes 

320 

Oatmeal 

460 

Bread 

1280 

Sugar  

345 

66 

0.29 

0.22 

1.12 

3505 

IV. 

Beef,  upper  shoulder 

Ham 

10 
6 
3 
2 
16 
12 
9 
1 

0.09 
0.06 
0.03 

'6!u4" 
0.01 
0  05 

0.13 
0.13 
0.02 
0.11 

0.04 

'6.'6i' 

'6.05" 
0.11 
0.38 
0.06 

800 
650 

Eggs,  two 

135 

Butter 

450 

Milk,  one  pint 

325 

Potatoes 

240 

Flour  

825 

Sugar  

115 

59 

0.28 

0.44 

0.60 

3540 

QUANTITY  AND  CHARACTER  OF  FOOD  NECESSARY. 


115 


Table  XVII— (Continued). 

Standard  Dietaries  {Hutchison. ) 

For  a  man   at  moderate  muscular  work. 


Food  Materials 

Amouut 

Proteids 

Fats. 

Carbo- 
hydrates 

Fuel  Value 

V. 
Sausage  

Ounces 

4 
14 

2 
16 

5 

2 
16 

9 

3 

Pounds 

0.03 
0.07 

'o"64' 

0.07 
0.01 
0.01. 
0.04 

Pounds 
0.11 

'b!ii' 

0.04 

0.01 
'o.'oi' 

Pounds 

"0A)5 
0.18 
0.10 
0  23 
0.28 
0.19 

Calories 
510 

Codfish 

140 

Butter 

450 

Milk,  one  pint 

325 

Beans 

505 

Rice 

205 

Potatoes 

420 

Bread  

640 

Sugar  

345 

71 

0.27 

0.28 

1.03 

3540 

VI. 
Beef 

8 
4 
3 

2.^ 
1 
16 

8       ■ 
2 
9 

0.08 
0.04 
0.03 

"0.62 
0.04 
001 
0.01 
0.05 

0.10 

0.04 

0.02 
0.13 
0  02 
0.04 

o.oi' 

0.65" 
0.08 
0.10 
0.32 
0  09 

560 

Mackerel,  salt 

230 

Eo;gs,  two 

135 

Butter 

565 

Cheese 

130 

Milk,  one  pint 

325 

160 

Rice 

205 

720 

Sugar  

175 

55 

0.28 

0.36 

0.64 

3205 

The  caloric  value  of  the  different  food-stuffs  has  been  estimated 
by  Atwater  as  follows : — 

Protein,  fuel  value,  4.1  calories  per  gram,  or  1859  calories  per 
pound.  Fats,  fuel  value,  9.3  calories  per  gram,  or  4218  calories  per 
pound.  Carbohydrates,  fuel  value,  4.1  calories  per  gram,  or  1859 
calories  per  pound. 

To  calculate  the  caloric  value  of  any  food,  multiply  the  number 
of  grammes  of  proteins  by  4.1,  the  number  of  grammes  of  fat  by  9.3^ 
and  the  number  of  grammes  of  carbohydrates  by  4.1. 

An  ideal  ration,  suggested  by  Mrs.  E.  H.  Eichards,  consists  of 
proteids,  106.80  grammes;  fats,  57.97  grammes,  and  carbohydrates, 
389.80  grammes.  On  the  other  hand,  Professor  Chittenden,  of  Yale, 
maintained  himself  for  nine  months  in  an  excellent  physical  condi- 
tion and  ill  perfect  nitrogenous  eciuililjrium  on  a  ration  which  con- 


116  TEXT-BOOK  OF  HYGIENE. 

sisted  of  about  one-tliird  the  usual  requirement  of  proteids,  Avhile  the 
total  daily  fuel-value  of  his  diet  was  only  about  one-half  the  usual 
requirement.  He  also  experimented  on  a  group  of  thirteen  volun- 
teers from  the  Hospital  Corps,  United  States  Army.  They  ranged  in 
age  from  21  to  43  years,  and  were  of  different  nationalities.  These 
men  did  average  work,  engaging  daily  in  gymnastics  and  other 
physical  labor.  Their  daily  menu,  with  slight  variations,  was  about 
as  follows : — 

Breakfast. — Boiled  hominy,  150  grammes;  milk,  125  grammes; 
sugar,  30  grammes;  butter,  10  grammes;  bread,  30  grammes;  cof- 
fee, one  cup. 

Dinner. — Split  pea  soup  (thick),  200  grammes;  bread,  75 
grammes;  mashed  potatoes,  100  grammes;  pickles,  30  grammes; 
coffee,  one  cup;    pie,  120  grammes. 

Supper. — Suet-pudding,  150  grammes;  apple-sauce,  125 grammes; 
crackers,  25  grammes;  tea,  one  cup. 

Total  nitrogen,  7.412  grammes.  Fuel  value,  2000  calories.  On 
this  diet,  poor  in  nitrogen,  these  men  lived  for  six  months,  and  at  the 
end  of  the  experiment  were  in  a  better  "physicifil  condition  than  when 
they  commenced. 

A  group  of  eight  young  college  athletes  were  kept  for  five  months 
on  a  diet  equally  poor  in  proteids,  with  the  result  that  they  gained  in 
strength. 

What  has  thus  far  been  said  about  the  ingredients  of  food  and 
the  ways  they  are  used  in  the  body  may  be  briefly  summarized  in  the 
following  schematic  manner   (Atwater)  : — 

Nutritive  ingredients  (or  nutrients)  of  food. 

Water. 


f  Edible  portion   < 

I       e.g.,   flesh   of   meat, 
t:,     3  1        J  yolk    and   white    of 

etc. 


Nutrients 


contains — 


Protein. 

Fats. 

Carbohydrates 
Mineral    matters. 


1^  Refuse. 

e.g.,  boneSj  entrails^  shells,  bran,  etc. 


QUANTITY  AND  CHARACTER  OF  FOOD  NECESSARY.  117 

Uses  of  nutrients  in  the  body. 


Protein Forms  tissue 

e.g.,  white  (albumen)  of 
eggs,  curd  (casein)  of 
milk,  lean  meat,  gluten 
of  wheat,  etc. 


All  serve  as  fuel  to 
yield  energy  in  the 
forms  of  heat  and 
muscular  power. 


Fats Are  stored  as  fat 

e.g.,  fat  of  meat,  butter, 
olive  oil,  oils  of  corn  and 
wheat,  etc. 

Carbohydrates    Are  transformed  into  fat. 

e.g.,  sugar,   starch,   etc. 

Mineral    matters     ( ash )  .  .     Share  in  forming  bone,  assist  in  digestion,  etc. 
e.g.,  phosphates   of   lime, 
potash,  soda,  etc. 

In  addition  to  maintaining  a  proper  proportion  between  the 
various  alimentary  principles,  it  is  necessary  to  vary  the  articles  of 
food  themselves,  otherwise  they  are  liable  to  prove  nauseating.  The 
necessity  of  variety  in  the  food,  in  order  to  preserve  the  appetite, 
is  familiar  to  every  one. 

If  a  man  wished  to  live  on  beef  alone  he  would  be  obliged  to 
eat  about  2  kilogrammes  per  day  in  order  to  get  a  sufficient  amount 
of  non-nitrogenous  food.  Of  potatoes,  in  order  to  get  enough  nitro- 
genous food,  he  would  have  to  eat  8  kilogrammes.  No  human  stomach 
could  prove  equal  to  the  task  of  digesting  this  excess  of  material.  On 
the  other  hand,  it  is  to  be  noted  how  perfect  the  combination  of  the 
various  principles  is  in  human  milk.  In  cow's  milk,  which  is  nearest 
in  composition  to  human  milk,  the  non-nitrogenous  principles  are 
deficient.  Hence,  the  important  practical  point  that  when  ordering 
milk  diet  for  a  patient  a  small  portion  of  carbonaceous  food  (bread, 
rice,  or  sugar)  must  be  added  if  the  standard  of  health  shall  be  reached 
or  maintained. 

Climate  has  probably  very  little  influence  upon  the  amount  of 
food  required  by  the  individual.  The  actual  quantity  of  food  con- 
sumed varies  little  between  various  races  or  in  different  parts  of  the 
earth.  It  is  true,  however,  that  a  larger  proportion  of  fat  is  required 
in  cold  climates.  That  fatty  articles  of  food  readily  undergo  oxi- 
dation and  furnish  a  large  amount  of  animal  heat  is  proven  both  by 
observation  and  experiment. 

The  albuminoid  proximate  principles  of  the  food,  proteids,  are 
represented  by  the  nitrogenous  constituents  of  organic  tissues.  These 
are  the  vitellin  and  albumin  of  eggs,  albumin,  fibrin,  globulin,  myosin, 
syntonin,  and  other  nitrogcnized  principles  of  flesh  and  blood;    the 


118  TEXT-BOOK  OF  HYGIENE. 

casein  of  milk,  the  gluten,  fibrin,  and  legmnin  of  cereal  and  legumin- 
ous seeds  and  plants,  gelatin,  and  cliondrin. 

Fat  constitutes  an  integral  component  of  animal  tissue,  and  is 
found  in  abundance  as  a  constituent  of  nerve-tissue,  marrow,  and 
subcutaneous  connective  tissue.  In  food  it  is  represented  especially 
in  the  fatty  tissue  of  meat,  the  yelk  of  eggs,  butter,  etc. 

The  carbohydrates  are  represented  especially  by  various  products 
of  the  vegetable  world,  as  sugar,  -starch,  dextrin,  etc. 

Water  and  various  other  inorganic  proximate  principles,  chief 
among  which  are  compounds  of  calcium,  sodium,  and  potassium, 
are  usually  found  in  sufficient  proportion  in  the  other  alimentary  sub- 
stances. 

The  food  should  be  taken  in  appropriate  quantities  and  properly 
prepared.  A  larger  quantity  than  necessary  may  overtax  the  diges- 
tive organs  and  thus  yield  less  than  the  required  amount  of  nutritive 
material  to  the  body. 

Physical  exertion  increases  the  consumption  of  fatty  principles. 
Hence,  as  in  the  case  of  the  athlete  or  prize-fighter  in  training, 
larger  quantities  of  these  principles  are  required  to  keep  the  nutrition 
of  the  body  at  the  standard  of  health.  During  mental  work,  however, 
less  carbohydrate  material  is  consumed  than  during  physical  labor. 

The  greater  consumption  of  carbohydrates  during  muscular  exer- 
cise is  shown  by  the  following  table,  which  gives  the  amounts  of 
carbon  dioxide  and  nitrogen  excreted  by  a  man  at  rest  and  during 
labor : — 

Table  XVIII. 


COj  Excreted. 

Nitrogen  Excreted. 

At  rest 

At  work 

912  grammes 
1284 

36.3  grammes. 
36.8         " 

In  youth  the  processes  of  combustion  (production  of  carbon 
dioxide)  go  on  with  greater  rapidity  than  after  adult  life  is  reached. 
For  this  reason  young  persons  rarely  get  fat,  the  fat-producing  food 
being  burnt  up  in  the  body  by  the  greater  metabolic  activity  of  the 
young  cell.  Hence,  fats  and  carbohydrates  should  form  a  larger 
relative  proportion  in  the  diet  of  the  young  than  in  that  of  grown 
persons. 


FOODS  OF  ANIMAL  ORIGIN.  119 

Low  external  temperature  causes  a  greater  and  more  rapid  con- 
sumption of  fat  than  high  external  temperature.  During  febrile 
conditions,  however,  the  destruction  of  stored-up  fat  in  the  body — 
the  wasting  away — is  one  of  the  most  notable  phenomena;  hence  the 
importance  of  supplying  fat  and  fat-producing  food  in  chronic  febrile 
diseases. 

"Der  Mensch  ist  was  er  isst/'  said  Ludwig  Feuerbach."  The  pun- 
gency of  the  epigram  is  somewhat  lost  in  the  translation,  which  is, 
literally,  "Man  is  what  he  eats.''  The  intimate  relations  of  mental, 
moral,  and  physical  conditions  of  health  to  the  quality  and  quantity 
of  food  deserve  the  earnest  attention  of  the  educated  physician  and 
sanitarian. 

CLASSIFICATION    OF   FOODS. 

Foods  and  victuals  are  generally  divided  into  foods  proper  and 
so-called  accessory  aliment.  The  classification  is  not  exact,  however, 
as  the  latter,  which  are  commonly  regarded  as  articles  of  luxury,  may 
under  certain  circumstances  become  necessities,  and  hence  should  not 
be  considered  as  forming  a  separate  class. 

Foods  are  either  of  animal  or  vegetable  origin.  Those  derived 
from  animal  sources  are  milk,  the  flesh  of  animals,  birds,  reptiles, 
and  fish,  and  the  eggs  from  the  three  last  named. 

The  foods  derived  from  the  vegetable  kingdom  comprise  the 
seeds  of  various  plants  (cereals,  legumes),  roots,  herbs,  ripe  fruits,- 
the  fleshy  envelopes  of  various  seeds  (which  may  properly  be  classed 
with  the  fruits),  and  various  fungi. 

There  are  also  in  common  use  a  number  of  beverages,  e.g.,  water, 
alcoholic  liquors,  alkaloid  infusions   (tea,  coffee,  cocoa),  etc. 

In  addition,  a  number  of  substances  or  compounds  are  in  common 
use  as  condiments.  Their  function  is  either  to  render  victuals  more 
palatable,  or  to  promote  digestion  and  assimilation.  Vinegar,  must- 
ard, and  common  salt  are  familiar  examples. 

FOODS    OF   ANIMAL    ORIGIN. 

Milk. — Human  milk  is,  so  far  as  known,  the  one  perfect  food  for 
man  found  in  nature.  It  contains,  in  proper  proportion,  representa- 
tives of  all  the  different  classes  of  proximate  principles  necessary  to 
nutrition.     One  hundred  parts  contain  about  2.5   parts   of  proteids 


"  Gottheit,  Freiheit  und  Unsterblichkeit  von  Standpunkt  der  Anthropolo- 
gie,  p.  .5. 


120  TEXT-BOOK  OF  HYGIENE. 

(casein  and  albumin)  ;  3.9  parts  of  fat  (butter)  ;  6.0  parts  of  sugar, 
and  .5  of  salts.  The  reaction  of  human  milk  is  slightly  alkaline; 
that  of  fresh  cow's  milk  is  neutral. 

In  human  milk  there  are  13.9  parts  of  solid  matter  to  87.1  of 
water,  while  in  cow's  milk  the  proportions  are :  Proteids,  4.0  per 
cent.;  fats,  3.4  per  cent.;  sugar,  3.8  per  cent.;  salts,  0.6  per  cent.,  or 
11.8  total  solids  and  88.2  water.'^ 

Of  the  solids  in  milk,  cow's  milk  contains  more  proteids,  while 
human  milk  is  richer  in  fats  and  sugar.  Hence,  in  using  cow's 
milk  as  a  substitute  for  human  milk  the  proteids  are  diluted  by  the 
addition  of  water,  and  the  non-nitrogenous  components  increased  by 
adding  sugar,  and,  under  some  circumstances,  fat  (cream). 

Goats'  and  asses'  milk  are  sometimes  used  as  substitutes  for 
human  milk,  but  they  do  not  approach  much  nearer  in  composition  to 
the  latter  than  does  cows'  milk. 

On  standing,  the  fatty  constituent  of  milk,  the  cream,  separates, 
and  on  account  of  its  less  specific  gravity  rises  to  the  surface,  where 
it  forms  a  layer  of  varying  thickness. 

After  standing  a  longer  interval  the  milk  undergoes  certain 
physical  and  chemical  changes.  Lactic  acid  is  formed  at  the  expense 
of  part  of  the  sugar  of  milk  (a  sort  of  fermentation  taking  place), 
and,  acting  upon  the  casein,  produces  coagulation.  This  is  the  so- 
called  "bonny-clabl3er."  AYhen  the  fermentation  continues,  especially 
under  a  slightly  elevated  temperature,  the  solid  portion  becomes  con- 
densed (curd),  and  a  sweetish-acid,  amber-colored  liquid,  the  whey, 
separates.  The  curd,  after  further  fermentation,  under  appropriate 
treatment,  becomes  converted  into  cheese. 

Whey  is  sometimes  used  alone  or  mixed  with  wine  as  an  article 
of  diet  for  the  sick. 

Butter  is  made  from  the  cream  by  prolonged  agitation  in  a 
churn.  The  fat-globules  adhere  to  each  other  and  form  a  soft, 
unctuous  mass,  of  a  yellowish  color,  solid  at  ordinary  temperatures. 
After  the  butter  is  all  removed  in  this  way  the  balance  of  the  cream 
remains  in  the  churn  as  buttermilk.  This  is  an  article  of  considerable 
nutritive  value,  although  its  excess  of  acid  renders  it  unsuitable  as  an 
article  of  diet  in  many  cases. 

The  specific  gravity  of  fresh  milk  should  not  be  below  1030. 
It  should,  however,  be  borne  in  mind  that  the  richest  milk  is  not 
always  that  which  has  the  highest  specific  gravity.  In  fact,  a  sample 
of  rich  milk,  containing  a  large  proportion  of  cream,  may  show,  when 

'  Average  of  a  number  of  analyses. 


FOODS  OF  ANIMAL  ORIGIN.  121 

tested  with  the  lactometer,  a  lower  specific  gravity  than  a  specimen  of 
much  poorer  milk.  Hence,  the  lactometer,  although  a  useful  instru- 
ment in  guarding  against  excessive  dilution  of  milk  with  water,  is  not 
a  very  trustworthy  guide  in  determining  the  quality  of  the  milk. 

Objections  are  often  urged  against  the  use  of  so-called  "skim- 
milk,"  i.e.,  milk  from  which  the  cream  has  been  removed.  In  some 
cities  in  this  country  the  police,  or  representatives  of  the  sanitary  au- 
thorities, seize  and  confiscate  all  skim-milk  found  in  possession  of 
dealers.  There  appears  to  be  no  rational  l)asis  for  the  opinion  held  by 
many  that  skim-milk  is  not  a  proper  and  useful  article  of  food.  Before 
the  lactic-acid  fermentation  has  taken  place  it  differs  from  fresh  milk 
merely  in  the  fatty  and  other  matters  removed  in  the  cream.  It  con- 
tains nearly  all  of  the  proteids,  sugar,  and  salts  of  whole  milk,  and 
may  be  used  as  an  article  of  food  with  great  advantage  and  entire 
safety.  In  certain  disordered  states  it  is  of  exceptional  value  as 
an  article  of  diet.  The  sole  objection  of  any  weight  to  skim-milk  is 
that  it  may  be  at  times  sold  fraudulently  as  fresh  milk.  This  is,  how- 
ever, a  question  of  little  sanitary  interest,  but  one  principally  of  com- 
mercial ethics. 

Milk  is  frequently  adulterated  by  the  addition  of  water.  More 
deleterious  substances  are  rarely  found.  An  excess  of  water  gives  the 
milk  a  bluish  tinge  and  reduces  its  specific  gravity.  The  addition  of 
water  may  become  especially  dangerous  by  introducing  the  virus  of 
some  of  the  acute  infectious  diseases.  Thus,  the  localized  epidemics 
of  typhoid  fever  have,  in  quite  a  number  of  instances,  been  traced  to 
mixing  the  milk  with  water  containing  the  germ  of  this  disease.  It 
should,  however,  be  stated  that  milk  which  contains  the  germ  of  ty- 
phoid fever  has  not  necessarily  been  adulterated  by  the  addition  of 
water.  The  typhoid  bacillus  may  have  been  introduced  with  the  water 
used  in  washing  the  can,  and  adhered  to  the  sides  of  the  latter.  In 
filling  the  can  with  milk  a  good  culture  medium  is  supplied  in  which 
the  typhoid  bacillus  flourishes.  Diphtheria  may  also  be  communicated 
through  the  milk,  by  the  latter  becoming  directly  contaminated  by 
the  specific  germs  of  this  disease. 

It  has  long  been  a  mooted  question  whether  acute  or  chronic 
infectious  diseases  of  the  milk-giving  animal  may  be  communicated 
to  persons  using  the  milk  of  such  animals.  While  there  is  little  posi- 
tive knowledge  upon  the  subject,  it  would  seem  prudent  to  avoid  the 
use  of  milk  from  diseased  animals,  if  possible,  or  to  destroy  any  or- 
ganic virus  the  milk  may  contain  by  previously  boiling  the  milk. 
After  thorough  boiling  little  fear  need  be  entertained  of  communi- 


122  TEXT-BOOK  OF  HYGIENE. 

eating  either  acute  or  chronic  infectious  diseases  through  this  medium. 
Demme  and  UfEehnann  have  reported  cases  which  seem  to  demon- 
strate the  possibility  of  tuberculous  infection  through  the  medium 
of  the  milk.  Professor  Bang,  of  Copenhagen,  made  a  series  of  ex- 
periments and  observations  which  led  him  to  the  conclusion  that  the 
milk  of  tuberculous  cows  and  tuberculous  women,  in  which  there  are 
no  lesions  in  the  mammary  gland,  only  exceptionally  contains  the 
contagion.  Professor  Bang,  at  the  same  time,  points  out  that  the  milk 
from  tuberculous  udders  is  extremely  dangerous,  and  that  the  tubercle 
bacilli  are  to  be  found  not  only  in  the  milk  itself,  but  in  the  cream, 
buttermilk,  and  butter  made  from  it;  and  that  such  milk  is  some- 
times infective  by  ingestion,  even  after  exposure  of  65°  C.  of  heat,  and 
by  injection  into  the  peritoneal  cavity  after  exposure  of  80°   C. 

The  infectiousness  of  the  milk  of  cows  suffering  from  splenic 
fever  (milzbrand,  anthrax)  has  been  proven  by  Bollinger  and  Feser. 
Anthrax  bacilli  have  been  found  in  such  milk  by  Chambrelent  and 
Moussons. 

The  agency  of  milk  in  the  spread  of  scarlet  fever  is  well  recog- 
nized, but  the  manner  in  which  the  contagion  gains  access  to  the 
milk  is  not  well  understood.  Several  years  ago  an  incident  happened 
in  England  which  seems  to  prove  a  close  connection  between  this 
widespread  and  fatal  disease  and  a  disorder  in  the  milk  cattle.  The 
evidence  in  support  of  this  view  is  as  follows:  Mr.  W.  H.  Power,  of 
the  English  Local  Government  Board,  was  detailed  to  investigate  cer- 
tain outbreaks  of  scarlet  fever  which  seemed  to  have  especial  relation 
to  the  milk-supply  from  a  particular  dairy-farm.  Upon  inspection 
this  dairy  was  found  to  be  in  excellent  sanitary  condition  as  regards 
cleanliness,  water-supply,  sewerage,  etc.,  and  for  a  time  considerable 
difficulty  was  experienced  in  locating  the  cause  of  the  outbreaks. 
Improbable  as  it  may  at  first  sight  appear,  it  seems  to  have  been  in- 
contestably  established  that  the  epidemics  of  scarlatina  were  due  to 
the  use  of  milk  obtained  from  cows  attacked  by  a  peculiar  disease 
manifested  by  a  vesicular  eruption  followed  by  ulceration  of  the  udder. 
The  chain  of  circumstances  connecting  the  disease  in  the  cows  with 
the  outbreak  of  scarlet  fever  in  certain  districts  in  London,  supplied 
with  milk  from  the  diseased  cows,  was  so  strongly  forged  by  the  able 
investigator  into  whose  hands  the  work  had  been  committed  by  the 
authorities,  that  hardly  a  doubt  can  exist  that  the  one  disease  owed 
its  origin  to  the  other. 

The  pathological  evidence  furnished  by  Dr.  Klein  lends  strong 
support  to  the  view  that  the  Hendon  cow  disease  and  scarlet  fever  are 


FOODS  OF  ANIMAL  ORIGIN.  123 

intimately  related  to  each  other.  A  bacterial  organism  was  found  in 
the  material  from  the  ulcerated  udders  of  the  sick  cows,  which  pre- 
sents similar  characteristics  to  a  micro-coccus  found  by  the  same  ob- 
server in  the  blood  of  scarlet-fever  patients.  These  results,  however, 
require  more  extended  investigations  before  they  can  be  unreservedly 
accepted. 

The  milk  of  cows  fed  upon  the  refuse  of  breweries  and  distilleries 
— "swill-milk" — is  believed  by  many  physicians  to  be  unwholesome. 
If  so,  it  is,  probably,  only  by  reason  of  the  unfavorable  hygienic  con- 
ditions under  which  the  animals  are  kept.  If  the  stables  are  clean, 
dry,  well- ventilated,  and  the  animals  receive  plenty  of  fresh  air  and 
exercise,  swill-fed  cows  should  produce  as  nutritious  milk  as  when  they 
are  fed  upon  different  food.  Much  of  the  agitation  against  "swill- 
milk"  is  more  prompted  by  political  demagogism  than  by  scientific 
knowledge. 

The  milk  of  animals  suffering  from  certain  diseases  is  often  dan- 
gerous to  health.  In  some  of  the  Western  and  Southern  United 
States,  cows  are  not  infrequently  attacked  by  an  acute  febrile  disease 
called  "the  trembles,"  from  one  of  the  prominent  symptoms.  The 
milk  of  cows  suffering  from  this  disease  produces  severe  gastro-intes- 
tinal  disorder,  collapse,  fever,  etc.,  in  the  consumer.  This  disease, 
called  "milk-sickness,"  is  fatal  in  a  pretty  large  proportion  of 
cases.  It  is  said  that  the  flesh  of  animals  with  "the  trembles"  will, 
if  eaten,  produce  similar  dangerous  effects.  A  late  writer  (Dr.  Beach, 
of  Ohio)  estimates  that  25  per  cent,  of  the  Western  pioneers  and 
their  families  died  of  this  disease. 

For  the  ready  determination  of  the  quality  of  milk,  instru- 
ments known  as  lactoscopes,  lactometers,  and  creamometers  are  used. 
The  lactoscope  indicates  the  opacity  of  the  milk,  upon  which  the  pro- 
portion of  cream  depends.  One  convenient  modification  of  the  lacto- 
scope is  the  little  instrument  termed  the  pioscope.  This  consists  of  a 
disk  about  6^/0  centimeters  in  diameter,  with  a  slight  depression  in 
the  centre.  A  little  milk  is  placed  in  the  depression  and  covered 
with  a  glass  disk,  clear  in  the  centre  and  opaque  around  the  border, 
which  is  divided  into  six  divisions  of  different  shades,  varying  from 
white  to  dark  gray.  The  quality  of  the  milk  is  marked  upon  the 
division  whose  color  corresponds  with  that  of  the  milk  in  the  centre. 

A  better,  but  still  not  very  accurate  indicator  of  the  quality  of  the 
milk,  is  the  creamometer.  This  consists  of  a  cylindrical  glass  vessel 
with  the  upper  half  divided  up  into  hundredths.  The  glass  is  filled 
up  to  the  zero  mark  with  milk,  and  allowed  to  stand  until  all  the 


124 


TEXT-BOOK  OF  HYGIENE. 


cream  has  separated.  The  thickness  of  this  layer  is  then  read  off  on 
the  scale.  In  Chevallier's  instrument,  10  per  cent,  of  cream  is  the 
minimum  proportion  that  should  be  furnished  by  the  milk. 

The  specific  gravity,  which  is  a  fair  guide  to  the  quality  of  the 
milk,  with  the  reservations  above  mentioned,  is  measured  by  means 
of  the  lactometer  or  lactodensimeter.  The  specific  gravity  of  good 
cows'  milk  should  not  be  less  than  1029. 


Fig.  10. — Chevallier's  Creamometer. 


In  order  to  prevent  the  rapid  fermentation  of  milk  various 
methods  of  preservation  have  been  adopted.  The  addition  of  alkalies, 
or  antiseptics,  retards  the  lactic-acid  fermentation,  while  the  abstrac- 
tion of  a  portion  of  the  water  and  addition  of  sugar  (condensed  milk) 
preserves  it  for  an  indefinite  time.  The  mere  addition  of  water  re- 
stores it  to  nearly  its  original  condition. 

Tyrotoxicon  in  Mill'. — This  substance,  first  found  in  poisonous 
cheese,  and  later  in  milk,  ice-cream,  custards,  etc.,  is  believed  by  Pro- 
fessor Vaughan  to  be  the  cause  of  true  cholera  infantum,  and  many  of 
the  clinical  phenomena  of  this  disease  lend  strong  support  to  such  a 
view,.  The  conditions  under  which  the  poison  is  developed  have  not  yet 
been  sufficiently  studied  to  enable  correct  conclusions  to  be  drawn. 
Recent  studies,  however,  indicate  that  the  summer  diarrhea  of  infants 


FOODS  OP  ANIMAL  ORIGIN.  125 

is  caused  by  putrefactive  bacteria  in  milk.  The  intimate  relation  be- 
tween milk  containing  large  numbers  of  bacteria  and  diarrheal  dis- 
eases in  infants  and  children  is  becoming  more  and  more  apparent. 

Butter. — Butter  is  of  especial  value  as  food  on  account  of  the 
large  amount  of  easily  digestible  fat  which  it  contains.  It  is  almost 
always  used  as  accessory  to  other  articles  of  food,  to  render  them 
more  palatable.  When  pure  and  fresh,  it  is  one  of  the  most  delicious 
of  foods.  It  soon  undergoes  the  butyric-acid  fermentation,  however, 
becoming  "rancid,"  as  it  is  termed,  when  it  is  unfit  for  food. 

The  great  demand  for  butter  and  its  consequent  high  price  have 
led  to  its  extensive  sophistication.  Butter  is  now  very  largely  sub- 
stituted by  an  artificial  substitute  termed  oleo-margarine,  or  butterine. 
This  artificial  butter  is  made  from  beef -suet  by  the  following  process : 
Fresh  beef-fat  is  melted  at  as  low  a  temperature  as  possible,  never 
higher  than  52°  or  53°  C.  [136°  to  128°  F.].  All  membrane  and  tissue 
are  then  removed,  and  the  resulting  clear  fat  is  put  into  presses,  where 
the  stearine  is  extracted.  The  liquid  fat,  free  from  tissue,  and  with 
nearly  all  its  stearine  removed,  is  known  as  "oleo-margarine  oil." 
The  next  step  in  the  process  is  the  "churning."  The  oil  is  al- 
lowed to  run  into  churns  containing  milk  and  a  small  quan- 
tity of  coloring-material  (annatto),  where,  by  means  of  rapidly- 
revolving  paddles,  it  is  churned  for  about  an  hour.  When  this  part 
of  the  process  is  complete,  the  substance  is  drawn  off  from  the  bottom 
of  the  churn  into  cracked  ice.  When  cool  it  is  taken  from  the  ice, 
mixed  with  a  proper  quantity  of  salt,  and  is  then  worked  like  butter 
and  put  into  firkins  for  the  market.  It  is  also  moulded  into  attrac- 
tive prints  in  imitation  of  dairy-butter.^  When  the  materials  from 
which  oleo-margarine  is  made  are  sweet  and  clean,  and  when  the  pro- 
cess of  manufacture  is  properly  conducted,  the  resulting  product  is 
an  entirely  harmless  article,  and  probably  differs  very  little  in  nu- 
tritive value  from  butter  itself.  The  only  objection  to  oleo-margarine 
is  a  commercial  one.  It  is  so  much  like  butter  that  dishonest  dealers 
find  it  possible  to  substitute  this  product  for  the  higher-priced  natural 
product. 

Cheese. — The  value  of  cheese  as  a  food  depends  upon  the  large 
amount  of  proteids  and  fat  which  it  contains.  The  rich  varieties  of 
cheese,  such  as  From  age  de  Brie  and  Eoquefort,  contain  on  an  average 
35  per  cent,  of  fat  and  27  per  cent,  of  proteid  compounds.  Parmesan 
contains  only  about  18  per  cent,  of  fat  and  nearly  40  per  cent,  of 


*Dr.  W.  K.  Newton,  Fifth  Annual  Report  of  the  State  Board  of  Health 
of  New  Jersey,  1881,  p.  107. 


126 


TEXT-BOOK  OF  HYGIENE. 


proteidSj  while  Edam  and  Cheshire  cheese,  which  may  be  considered 
as  standing  about  midway  between  the  above,  contain  30  per  cent,  of 
fat  and  nearly  28  per  cent,  of  proteids.  From  these  figures  it  ap- 
pears that  cheese  is  one  of  the  most  nutritious  aliments  obtainable, 
but  it  cannot  be  eaten  in  large  quantities  at  a  time,  as  it  is  exceedingly 
liable  to  cause  disturbances  of  the  digestive  organs.  The  constipating 
property  of  cheese  is  well  Icaown  to  the  public. 

The  relative  value   of  different  kinds   of   cheese  in   alimentary 
principles  is  given  in  the  following  table: — 

Table  XIX. 


Kind  of  Cheese. 

Proteids 
(percent.). 

Fats 
(per  cent.). 

Sugar 
(percent.). 

Salts 
(percent.). 

Cheshire 

27.68 

27.46 

5.89 

5.01 

Edam 

24.07 

30.26 

4.48 

4.91 

Holland 

29.48 

26.71 

2.27 

4.62 

Roquefort 

Neufchatel 

27.69 
17.44 

33.44 

40.80 

3.15 

5.21 

5.35 
2.05 

Parmesan 

41.19 

19.52 

1.18 

6.31 

Cheese  is  not  often  adulterated.  The  only  articles  used  with 
success  in  its  sophistication  are  lard  and  oleo-margarine,  which  are 
incorporated  with  the  casein  during  the  process  of  manufacture.  It 
sometimes  undergoes  chemical  changes  which  render  it  intensely 
poisonous  Avhen  eaten. 

Professor  V.  C.  Vaughan,  of  the  University  of  Michigan,  has 
ascertained  that  the  substance  causing  the  poisonous  symptoms  is  a 
chemical  compound  termed  by  him  tyrotoxicon.  This  same  poison 
has  also  been  found  by  Professor  Vaughan  and  other  chemists  in 
ice-cream  and  fresh  milk,  which  produced  poisonous  symptoms  when 
consumed.  The  poison  is  supposed  to  be  a  ptomaine  produced  by  the 
agency  of  a  micro-organism,  which  has,  however,  not  yet  been  isolated. 

Meat. — The  flesh  of  mammals,  reptiles,  birds,  fish,  and  inver- 
tebrate animals  is  used  as  food  by  man.  Falck^  has  classified  the 
varieties  of  animals  which  furnish  food  to  the  inhabitants  of  Europe. 
There  are  47  varieties  of  the  mammalian  class,  105  of  birds,  7  of 
amphibia,  110  of  fish,  and  58  of  invertebrates. 


®  Das    Fleiseh,   Gemeinverstaendliches    Handbuch    der   Wissenschaftliclieii 
imd  Praktisclien  Fleischkunde. 


FOODS  OF  ANIMAL  ORIGIN. 


127 


Meat  is  the  most  important  source  of  proteids  in  the  food.  In 
the  more  commonly  used  varieties  of  meat  the  proteids  and  fats  consti- 
tute from  25  to  50  per  cent,  of  the  entire  bulk,  the  proportion  depend- 
ing largely  upon  the  age  of  the  animal  and  its  bodily  condition.  The 
following  table  shows  the  influence  of  these  two  factors  upon  the  rela- 
tive proportions  of  the  fats  and  proteids  in  the  meat : — 

Table  XX. ^^ 


Proteids  (jDcr  cent.) 


Fats  (per  cent.). 


Moderately  fat  beef 
Lean  beef  .     .     .     . 

Yeal 

Very  fat  mutton 
Fat  pork     .     .     .     . 
Lean  pork  .     .     .     . 

Hare 

Lean  chicken  .  .  . 


21.39 
20.54 
10.88 
14.80 
14.54 
19.91 
23.34 
19.72 


5.19 
l.tS 
1A1 
36.39 
3t.34 
6.81 
1.13 
1.42 


The  flesh  of  animals,  which  is  neutral  in  reaction  immediately 
after  death,  soon  becomes  acid  in  consequence  of  the  formation  of 
lactic  acid.  The  acid,  acting  upon  the  sarcolemma  and  the  muscular 
fibre,  renders  it  softer  and  more  easily  permeable  by  fluids  when  cook- 
ing, and  more  susceptible  to  the  action  of  the  gastric  juice  when  the 
meat  is  taken  into  the  stomach. 

Certain  kinds  of  meat — mutton  and  venison,  for  example —  are 
often  kept  so  long  before  being  eaten  that  a  considerable  degree  of 
putrefaction  has  taken  place  when  they  are  brought  upon  the  table. 
The  wisdom  of  this  practice  is  questionable  from  a  hygienic  point  of 
view. 

Meat  is  sometimes  eaten  raw,  but  it  is  usually  first  cooked.  The 
methods  of  cooking  in  general  use  are  boiling,  frying,  roasting,  broil- 
ing, and  baking.  By  either  of  these  methods  of  cooking,  when  prop- 
erly carried  out,  the  nutritious  properties  of  the  meat  are  preserved, 
and  it  is  rendered  digestible.  The  culinary  art  deserves  the  closest 
attention  of  students  of  hygiene. 

A  number  of  soluble  preparations  of  meat  (beef -extract,  beef- 
essence,  beef-juice)  are  found  in  the  market,  and  highly  recommended 
as  containing  all  the  nutritious  qualities  of  the  meat  from  which  they 


'"Abridged  from  Loebisch;    article  "Flcisch"  in  Realencyclopaedie  d.  ges. 
Heilkunde,  vol.  v,  p.  340. 


128  TEXT-BOOK  OF  HYGIENE. 

are  prepared.  These,  and  similar  products  of  domestic  preparation 
(broths  and  teas),  contain  in  reality  very  little  nutritive  material,  but 
are  of  use  almost  solely  as  stimulants  to  the  appetite  and  digestion. 
They  have  a  place  in  the  dietary  of  the  sick  but  their  nutritive  value 
is  small. 

On  the  other  hand,  a  number  of  partly  or  wholly  predigested 
(peptonized  or  pancreatized)  preparations  of  meat  are  offered  for  sale, 
many  of  which  have  a  high  nutritive  value.  They  cannot,  however, 
be  used  as  articles  of  diet  except  for  a  short  time,  or  as  a  temporary 
succedaneum  for  meat  in  diseases  attended  with  weakness  or  derange- 
ment of  the  digestive  organs.  Most  of  the  predigested  beef-prepara- 
tions on  the  market  owe  their  effect  to  the  large  amounts  of  alcohol 
which  they  contain. 

Meat  may  be  unfit  for  food  from  various  causes.  Thus  the  flesh 
of  animals  djing  from  certain  diseases — splenic  fever,  pleuro-pneu- 
monia,  tuberculosis  in  its  advanced  stages,  cow-  or  sheep-  pox — should 
not  be  used  as  food  when  it  can  be  avoided.  Cases  are  on  record 
proving  the  poisonous  character  of  meat  from  animals  which  suffered, 
at  the  time  of  death,  from  some  of  the  above-mentioned  diseases. 
The  most  important  condition  to  be  borne  in  mind  is  that  certain 
parasites  (trichina  spiralis,  echinococcus,  cysticercus),  which  fre- 
quently infest  the  flesh  of  animals,  especially  hogs,  not  infre- 
quently give  rise  to  serious  or  even  fatal  diseases  in  persons  consum- 
ing such  meat.  Any  meat  containing  these  parasites  or  suspected 
of  containing  them,  should  therefore  not  be  used  as  food  unless  pre- 
cautions be  first  taken  to  destro}^  the  life  of  the  parasite. 

Of  the  parasites  mentioned  the  trichina  spiralis  is  the  most  im- 
portant in  this  connection,  as  it  frequently  occurs  in  the  flesh  of  hogs, 
rats,  dogs,  cats,  and  other  carnivorous  animals.  Eats  are  said  to  be 
infested  with  the  parasite  more  frequently  than  any  other  animals. 
The  trichinae  are  found  in  two  forms,  one,  the  mature  form,  inhabiting 
the  intestinal  canal.  The  immature  form,  or  muscle  trichinfe,  are 
found  in  striped  muscle,  coiled  into  spirals  and  encysted  in  a  fibrous 
capsule.  They  gain  access  to  their  host  in  the  following  manner: 
Flesh  containing  living  trichinae  is  taken  into  the  stomach,  where  the 
muscular  tissue  and  the  fibrous  envelope  are  dissolved,  and  the  in- 
closed worms  set  free.  These  mature  in  the  intestinal  canal,  where 
sexual  reproduction  takes  place,  and  the  young  embryos  pass  through 
the  intestinal  walls  and  other  tissues  until  they  become  imbedded  in 
striated  muscle.  Localized  epidemics  of  trichinosis  have  been  re- 
ported in  this  country  and  Europe,  and  in  nearly  every  instance  the 


FOODS  OF  ANIMAL  ORIGIN.  129 

source  of  the  disease  has  been  traced  to  the  ingestion  of  uncooked 
pork.  Meat  known  to  be  trichinous  should  not  be  used  unless  in  times 
of  great  scarcity.  It  may,  however,  be  rendered  innocuous  by  thorough 
cooking.  A  temperature  of  60°  to  70°  C.  (140°  to  160°  F.) 
destroys  the  life  of  the  parasite  and  renders  the  meat  safe.  On  ac- 
count of  the  frequent  occurrence  of  trichinge  in  pork,  this  meat  should 
never  be  eaten  unless  thoroughly  cooked.  It  has  been  ascertained 
that  salted  and  smoked  pork  is  not  free  from  danger,  as  the  parasites 
are  not  killed  in  the  process  of  curing  the  meat.  Hence,  ham  and 
sausage  should  not  be  eaten  raw,  as  the  danger  from  these  articles  is 
almost  equally  as  great  as  from  fresh  pork. 

Cysticercus  cellulosa,  the  transition  form  of  one  variety  of  tape- 
worm, and  which  is  the  parasite  in  measly  pork,  may  also  gain  en- 
trance to  the  human  body,  and,  failing  to  undergo  development,  cause 
very  serious  lesions  of  various  organs  and  tissues.  The  frequency  of 
tape-worm  is  evidence  that  pork  is  often  thus  diseased. 

The  use  of  partially  decayed  meat  or  fish  has  often  been  the  cause 
of  serious  or  fatal  illness.  Sometimes  the  illness  partakes  of  the 
character  of  septic  infection.  In  these  cases  it  is  probable  that  the 
morbid  process  is  due  to  the  action  of  the  organisms  of  putrefaction. 
In  other  cases  the  symptoms  are  widely  different.  These  cases  have 
been  the  source  of  much  perplexity  to  physicians  and  toxicologists 
until  very  recently.  Selmi,  Husemann,  Brouardel,  Casali,  and  others 
have  drawn  attention  to  certain  intensely  poisonous  chemical  com- 
pounds found  in  decomposing  flesh,  and  which  have  been  named  by 
Selmi  ptomaines.  While  there  is  still  much  uncertainty  concerning 
the  nature  of  these  compounds,  it  seems  pretty  well  established  that 
when  flesh  undergoes  decomposition,  in  the  absence  of  oxygen,  certain 
unstable  chemical  combinations  are  formed  which  act  as  violent 
poisons.  Selmi,  followed  by  most  toxicologists,  believes  these  com- 
pounds to  be  alkaloids,  analogous  to  the  vegetable  alkaloids,  such  as 
morphine,  atropine,  etc.  Casali,  on  the  other  hand,  disagrees  with  this 
opinion,  and  believes  the  ptomaines  to  be  amido  compounds.  Huse- 
m.ann  regards  Casali's  hypothesis  as  plausible,  inasmuch  as  the  for- 
mation of  amido  compounds  in  animal  and  vegetable  bodies  during 
decomposition  is  well  established. 

The  form  of  poisoning  due  to  the  organisms  of  putrefaction  is 
not  infrequent.  An  extensive  outbreak  of  this  nature  occurred  at 
Andelfingen,  in  Switzerland,  in  1839.  A  musical  festival  was  held, 
at  which  there  were  over  700  present.  Out  of  these  444  were  suddenly 
attacked  by  violent  gastro-enteric  and  nervous  symptoms.    Ten  of  the 

9 


130  TEXT-BOOK  OF  HYGIENE. 

patients  died.  The  illness  was  traced  to  roast  veal,  which  had  been 
kept  in  a  warm  place  for  two  da3'^s  after  roasting,  and  which  was  prob- 
aly  in  a  state  of  partial  decomposition. 

The  class  of  cases  which  seem  more  probably  due  to  the  action 
of  ptomaines  or  related  poisons,  have  been  frequently  observed  after 
eating  sausages  or  canned  meats.  Sausage  poisoning  is  not  rarely  ob- 
served in  Germany.  It  has  been  ascertained  that  the  internal  portions 
of  the  sausage  are  the  most  poisonous.  It  is  supposed  that  the 
ptomaines,  which  are  formed  in  the  absence  of  oxygen,  are  the  active 
agents  in  the  production  of  the  train  of  symptoms.  Poisoning  by 
canned  meat  seems  to  be  due  to  a  similar  poison. 

In  July,  1885,  an  outbreak  of  disease,  due  to  eating  unwholesome 
beef,  was  caused  at  Momence,  Illinois.  Chemical  examination  of 
specimens  of  the  meat  showed  the  presence  of  an  alkaloidal  body 
which  was  believed  to  be  a  ptomaine,  but  its  nature  was  not  definitely 
determined. 

Fish,  oysters,  crabs,  and  lobsters  frequently  give  rise  to  symp- 
toms of  poisoning.  In  most  of  these  cases  the  poisoning  is  probably 
due  to  partial  decomposition,  but  it  is  a  well-known  fact  that  oysters 
and  crabs  are  unfit  for  food  at  certain  seasons.  Some  persons,  how- 
ever, are  subjects  of  a  peculiar  idios^Ticrasy,  in  consequence  of  which 
shell-fish  always  produce  certain  unpleasant  symptoms,  among  which 
nettle-rash  and  a  choleraic  attack  are  most  prominent. 

That  form  of  fish-poisoning  known  among  the  Spaniards  in  the 
Vfest  Indies  as  siguaiera  is,  however,  very  grave.  The  mortality  is 
large,  and  in  many  cases  death  succeeds  rapidly  upon  the  attack.  The 
sjTmptoms  are  as  follow :  Sometimes  suddenly,  sometimes  preceded 
by  dizziness  and  indistinct  vision,  great  prostration  and  paralysis 
occur.  Often  death  follows  the  onset  of  the  symptoms  in  two  and 
three  hours.  Exceptionally  in  less  than  twenty  minutes.  In  most 
cases  consciousness  is  totally  lost ;  in  others  it  persists,  with  interrup- 
tions, until  death.  Sensation  and  the  powers  of  speech  and  deglutition 
fail.  The  jaw  muscles  become  paralyzed,  the  pulse  is  slowed,  and  the 
temperature  diminished.  There  is  sometimes  vomiting,  but  no  purg- 
ing. The  secretion  of  the  kidneys  is  also  checked.  Dr.  Mc Sherry 
states^^  that  he  has  seen  all  these  symptoms  produced  by  eating 
oysters,  lobsters,  and  crabs,  unseasonably. 

In  Eussia  a  form  of  poisoning  has  often  been  observed  which  re- 
sults from  eating  salted  sturgeon.  In  the  fresh  state  these  fish  are 
perfectly  wholesome,  bu!t  when  salted  and  eaten  raw  they  produce  a 

"  Health  and  How  to  Promote  itj  p.  143. 


FOODS  OF  ANIMAL  ORIGIN.  131 

very  fatal  illness.  The  mortality  is  said  to  reach  50  per  cent,  of 
those  attacked.  No  cases  traceable  to  this  cause  have  been  observed 
in  this  country.  Kecent  investigations  show  that  many  cases  of  meat 
poisoning  are  caused  by  the  bacillus  of  Gaertner,  which  belongs  to  the 
colon  group  of  intestinal  bacteria,  while  other  cases  are  caused  by  a 
bacillus  discovered  by  Van  Ermengem  in  1896 — the  bacillus  botulinus. 

It  has  been  shown,  beyond  question,  that  the  flesh  of  beeves  suf- 
fering, when  killed,  from  splenic  fever,  will  produce  this  disease  in 
the  human  subject. 

In  1874  an  extensive  and  violent  outbreak  of  an  acute  disease, 
characterized  by  vomiting  and  purging,  fever  and  dizziness,  occurred 
at  Middleburg,  in  Holland.  Three  hundred  and  forty-nine  persons 
were  attacked,  of  whom  6  died.  The  outbreak  was  traced  to  eating 
liver-sausage  (Leberwurst),  in  which  the  characteristic  bacillus  of 
splenic  fever  was  found  on  microscopic  examination.  In  July,  1877, 
an  outbreak  of  choleraic  disease,  from  eating  carbuncular  meat,  oc- 
curred in  the  town  of  Wurzen.  In  the  latter  epidemic  the  bacillus  of 
splenic  fever  (Bacillus  antliracis)  was  found  in  the  intestinal  canal 
and  in  the  blood  of  those  attacked. 

In  Detmold,  in  Germany,  an  outbreak  of  violent  gastro-intestinal 
inflammation,  accompanied  by  a  high  fever,  occurred.  Among  the 
150  persons  attacked  3  died.  The  disease  was  traced  to  eating  the 
meat  of  a  cow  suffering,  before  death,  from  pleurisy  (probably  pleuro- 
pneumonia). 

In  July,  1880,  72  persons  who  had  eaten  of  certain  beef  and  ham- 
sandwiches  in  Welbeck,  England,  were  attacked  by  choleraic  diar- 
rhea; 4  of  the  cases  died.  Inflammation  of  the  lungs  and  small 
intestines  was  the  most  prominent  pathological  condition  found  post- 
mortem. The  smaller  blood-vessels  of  the  kidneys  were  filled  with 
finger-shaped  bacilli,  which,  when  cultivated  and  inoculated  into 
guinea-pigs,  rats,  and  white  mice,  produced  similar  pathological  con- 
ditions. At  Nottingham,  England,  in  1881,  a  number  of  persons  were 
attacked  by  a  similar  train  of  symptoms  after  eating  baked  pork.  One 
case  terminated  fatally  out  of  the  15  attacked.  It  is  uncertain  whether 
the  meat  in  these  two  instances  was  from  diseased  animals  or  whether 
it  had  undergone  partial  decomposition.  The  former  is  the  more 
probable  supposition,  although  the  organisms  found  were  neither  those 
of  splenic  fever  nor  swine  plague,  but  resembled  those  of  symptomatic 
anthrax  (black  leg  or  black  quarter). 

'V\TnethGr  the  flesh  of  tuberculous  animals  can  communicate  tuber- 
culosis to  the  consumer  is  still  an  unsettled  question.    Foreign  veterin- 


132  TEXT-BOOK  OF  HYGIENE. 

arians  and  hygienists  who  have  studied  the  question  incline  to  the  view 
that  there  is  danger  of  such  transmission.  At  the  International  Sani- 
tary Congress  of  1883,  at  Brussels,  the  subject  was  discussed,  and  M. 
Lydtin,  the  chief  veterinary  surgeon  of  the  Grand  Duchy  of  Baden, 
submitted  the  following  propositions,  which  were  adopted  by  the  Con- 
gress— 

1.  That  the  flesh  and  viscera  of  tuberculous  animals  may  be  used 
as  food,  provided  the  disease  is  only  commencing,  the  lesions  extend- 
ing to  but  a  small  part  of  the  body,  the  lymphatic  glands  being  still 
healthy;  provided  the  tubercle  centers  have  not  undergone  softening, 
and  provided  the  carcass  is  well  nourished  and  the  flesh  presents  the 
characters  of  meat  of  the  first  quality.  2.  That  the  flesh  of  animals 
showing  very  pronounced  tuberculous  infection  should  be  saturated 
with  petroleum,  and  afterward  burned  under  the  direction  of  the 
police.  3.  That  the  milk  from  cows  affected  with  pulmonary  phthisis, 
or  suspected  of  having  it,  should  not  be  consumed  by  man  or  other 
animals,  and  the  sale  of  it  should  be  strictly  prohibited. 

The  congress  for  the  study  of  tuberculosis,  which  met  in  Paris 
in  1888,  adopted  resolutions  of  a  more  decided  character  against  the 
use  of  meat  and  milk  from  tuberculous  animals.  Eecent  investiga- 
tions fully  substantiate  the  opinions  expressed  at  these  congresses. 

Certain  animals  can  devour  with  impunity  substances  which  are 
intensely  poisonous  to  human  beings.  The  flesh  of  the  animals  may 
be  impregnated  with  these  poisons,  and  cause  serious  and  fatal  illness 
in  persons  partaking  of  it.  In  this  way  may,  perhaps,  be  explained 
the  cases  of  poisoning  sometimes  following  the  eating  of  partridges 
and  other  birds. 

The  prevention  of  disease  from  tainted  meat  is  one  of  the  most 
important  problems  of  public  hygiene.  Food  animals  should  be  in- 
spected by  qualified  inspectors  before  slaughtering,  to  exclude  animals 
suffering  from  diseases  that  would  vitiate  the  meat.  When  the  meat 
is  exposed  for  sale  upon  the  dealer's  stall  it  should  be  again  inspected, 
and  all  found  unfit  for  use  as  food  confiscated  and  destroyed.  Meat, 
in  which  the  presence  of  trichinge  or  other  parasites  is  suspected, 
should  be  examined  microscopically.^^  The  recent  disclosures  in  con- 
nection with  the  scandalous  neglect  of  sanitary  precautions  in  the 

"The  prevention  of  the  diseases  of  animals  by  National  and  State  au- 
thorities is  one  of  the  most  logical  and  thorough-going  means  of  preventing 
disease  from  unAvholesome  meat.  The  American  Public  Health  Association  has 
for  some  years  devoted  considerable  attention  to  the  investigation  of  the  dis- 
eases of  animals  and  means  for  their  prevention.  The  Department  of  the  In- 
terior of  the  National  Government  has  likewise  made  the  diseases  of  cattle 
and  hogs  a  subject  of  study  and  published  some  valuable  reports  thereon. 


FOODS  OF  VEGETABLE  ORIGIN.  133 

packing-houses  in  Chicago  emphasize  the  necessity  of  great  vigilance 
in  the  inspection  of  meats  at  these  establishments.  However,  these 
disclosures,  unpleasant  as  they  were  at  the  time,  led  to  prompt  eradi- 
cation of  the  existing  evils. 

Eg-gs. — Although  eggs  contain  a  large  amount  of  the  proteid  and 
fatty  alimentary  principles,  their  value  as  food  has  probably  been 
greatly  overrated.  The  savory  taste  and  ready  digestibility  of  eggs 
have,  however,  rendered  them  a  popular  article  of  food.  For  obvious 
reasons,  the  eggs  of  the  common  barnyard  fowl  are  most  frequently 
used,  those  of  ducks  and  geese  being  far  inferior  in  flavor  to  the  first 
named,  and  being  likewise  less  easily  obtained. 

The  method  of  cooking  eggs  is  generally  supposed  to  have  con- 
siderable influence  upon  their  digestibility.  According  to  Dr.  Beau- 
mont's experiments  made  on  Alexis  St.  ]\Iartin,  raw  eggs  are  digested 
in  one  and  a  half  to  two  hours,  fresh-roasted  in  two  hours  and  fifteen 
minutes,  soft-boiled  or  poached  in  three  hours,  and  hard-boiled  or 
fried  in  three  and  a  half  hours.  These  experiments  are,  however,  of 
very  little  value  as  a  basis  for  general  conclusions.  It  is  probable 
that  a  hard-boiled  egg  is  quite  as  easily  digested  in  the  healthy  stom- 
ach as  a  raw  one,  if  care  be  taken  to  masticate  it  well  and  eit  bread 
with  it,  so  that  it  is  introduced  into  the  stomach  in  a  finely-divided 
state. 

Eggs  readily  undergo  putrefaction,  when  sulphuretted  hydrogen 
is  formed  in  them  in  large  quantities.  When  this  has  taken  place  they 
are  manifestly  unfit  to  be  used  as  food. 

FOODS   OF  VEGETABLE   ORIGIN. 

Bread. — The  various  cereal  grains,  when  ground  into  flour,  are 
used  in  making  bread.  The  flours  of  wheat,  rye,  barley,  buckwheat, 
and  Indian  corn  are  almost  exclusively  used  in  bread-making.  The 
bran  or  cortical  portion  of  grain  contains  a  larger  percentage  of  pro- 
teid principles  than  the  white  internal  portion;  hence,  flours  made 
from  the  whole  grain  (bran  flour,  Graham  flour)  if  finely  ground  are 
more  nutritious  than  the  white  flours.  The  latter  are,  however,  more 
digestible,  and  hence  furnish  a  larger  proportion  of  nutriment,  be- 
cause the  principles  contained  in  white  flours  are  absorbed  and  as- 
similated to  a  greater  degree. 

Good  bread  should  be  light,  porous,  and  well  leaked.  The  light- 
ness anrl  porosity  are  due  to  carbon-dioxide  gas  imprisoned  in  cavities 
of  the  dough  during  the  process  of  bread-making.     By  adding  yeast 


134  TEXT-BOOK  OF  HYGIENE. 

to  the  dough  a  fermentation  is  caused  in  the  latter,  in  consequence  of 
which  a  portion  of  the  starch  is  converted  into  sugar,  and  then  into 
alcohol  and  carbon  dioxide.  During  the  process  of  mixing  the  dough 
the  entire  mass  becomes  permeated  by  the  gas,  which,  on  heating,  ex- 
pands and  leaves  the  numerous  large  and  small  cavities  throughout 
the  loaf  which  indicate  properly  made  bread. 

Instead  of  yeast  some  persons  use  leaven,  which  is  simply  a  por- 
tion of  fermenting  dough  saved  from  a  previous  baking.  A  small 
quantity  of  this  added  to  a  mass  of  dough  starts  up  the  fermentation 
in  a  similar  manner  to  that  of  yeast. 

The  production  of  carbon  dioxide  by  fermentation  in  the  dough 
goes  on  at  the  expense  of  part  of  the  starch.  It  has  been  proposed, 
therefore,  to  supply  the  carbon  dioxide  from  without,  thus  saving 
the  entire  amount  of  the  carbohydrates  present  in  the  flour.  This 
is  accomplished  in  two  ways — first,  by  the  use  of  some  alkaline  car- 
bonate or  bicarbonate  (bicarbonate  of  sodium,  carbonate  of  ammo- 
nium), the  carbon  dioxide  being  set  free  on  the  application  of  heat; 
or,  secondly,  by  forcing  gas,  previously  prepared,  into  the  dough  by 
means  of  machinery. 

Flour  is  not  infrequently  adulterated  with  chalk,  gypsum,  pipe- 
clay, and  similar  articles.  These  are  easily  detected  by  adding  a  min- 
eral acid,  which  produces  effervescence  when  it  comes  in  contact  with 
the  alkaline  carbonate  used  as  an  adulterant.  Potato-  and  Ijean-  meals 
are  also  used  as  adulterants  of  the  higher  grades  of  flour.  Bakers 
often  mix  alum  with  inferior  grades  of  flour.  This  imparts  a  greater 
degree  of  whiteness  to  the  bread,  and,  in  addition,  enables  it  to  retain 
a  large  proportion  of  water,  thereby  increasing  the  weight  of  the 
loaf. 

Formerly  diseased  grain  (ergotized  rye)  often  caused  outbreaks 
of  disease  when  the  flour  made  from  the  diseased  grain  was  used  in 
bread-making.  At  present  time  such  accidents  rarely  occur.  In  some 
parts  of  Italy  it  is  said  that  an  endemic  disease — pellagra — is  caused 
by  the  consumption  of  diseased  Indian  corn.  The  evidence  in  favor 
of  this  view,  is,  however,  not  unquestioned. 

Potatoes  and  rice  are  often  used  with  satisfaction  as  substitutes 
for  bread.  They  both  contain  a  large  proportion  of  carbohydrates. 
Indian  corn  (hominy)  and  oatmeal  are  likewise  wholesome  and  nutri- 
tious foods  of  this  class. 

The  leguminous  seeds  (beans,  peas,  lentils)  furnish  a  food  con- 
taining a  large  percentage  of  proteids.    According  to  the  analyses  of 


FOODS  OF  VEGETABLE  ORIGIN. 


135 


Koenig^^  the  average  composition  of  the  most  frequently  used  legumes 
in  the  dried  condition  is  as  follows : — 


Table  XXI. 


Beans. 

Peas. 

Lentils. 

Ground-nuts  1* 

Water,  per  cent.     .     .     . 
Solids,  per  cent.      .     .     . 

13.6 

86.4 

14.3 

85.7 

12.5 

87.5 

6.5 
93.5 

Proteids,  per  cent.      .     . 

Fats 

Carbohydrates,  per  cent. 
Cellulose,  per  cent.     .     . 
Ash 

23.1 
2.3 

53.6 
3.9 
3.5 

22.6 
1.7 

53.2 
5.5 
2.7 

24.8 

1.9 
54.7] 

3.6; 

2.5 

28.2 
46.4 

15.7 

3.2 

Beans,  peas,  and  lentils  are  often  added  to  other  articles  of  food 
with  advantage.  An  important  article  of  food  for  armies  has  been 
made  of  various  legumes  ground  into  flour  and  mixed  with  fat,  dried 
and  powdered  meat,  salt,  and  spice.  This  constitutes  the  so-called 
"Erbswurst,"  or  pea-sausage,  which  formed  such  an  important  part  of 
the  dietary  of  the  German  army  in  the  Franco-German  war  of  1871. 
Bean-  and  pea-  meals  are  also  used  sometimes  as  additions  to  other 
flours  in  bread-making.  The  dried  leguminous  fruits  cannot  be  used 
as  regular  articles  of  diet,  however,  as  they  soon  pall  upon  the  taste, 
and  produce  indigestion,  nausea,  and  other  intestinal  derangements. 

Green  Vegetables. — The  plants  usually  classed  together  as 
"vegetables,^'  the  products  of  the  market-garden  or  truck-farm,  com- 
prise cabbages,  turnips,  parsnips,  onions,  beets,  carrots,  tomatoes,  let- 
tuce, green  peas  and  beans,  and  similar  articles.  They  all  contain 
a  large  proportion  of  water,  a  variable  proportion  of  sugar,  and  a 
small  percentage  of  proteid  principles.  Much  of  their  palatability  and 
digestibility  depends  upon  the  micthods  by  which  they  are  prepared  for 
the  table.  All  garden  vegetables  should  be  used  soon  after  being 
gathered,  as  they  rapidly  undergo  decomposition,  and  are  liable  to 
produce  derangements  of  the  digestive  organs  if  used  under  these 
conditions. 

Fruits  and  Nuts. — These  generally  contain  large  quantities  of 
sugar  and  fats.  They  form  agreeable  additions  to  other  articles  of 
diet,  but  are  insufficient  to  sustain  life.     The  use  of  fruits  usually 


"Die  Mensehlichon  Naln-ungs  und  Genussmittel,  ii,  p.  288. 
"The  American  pea-nut,  the  fruit  or  nut  of  Arachis  hypogosa. 


136  TEXT-BOOK  OF  HYGIENE. 

produces  copious  intestinal  evacuations,  and  tliey  are,  therefore,  espe- 
cially to  be  recommended  to  persons  of  sedentary  occupations,  in  whom 
torpidity  of  the  bowels  is  so  frequently  present. 

Condiments. — Various  aromatic  herbs  and  seeds  are  used  as  addi- 
tions to  other  articles  of  food,  to  increase  their  sapidity  and  to  pro- 
mote a  larger  flow  of  saliva  and  gastric  juice,  and  so  assist  digestion. 
Mustard,  pepper,  allspice,  and  vinegar  are  the  principal  condiments. 
Within  certain  limits  they  are  not  injurious,  but  the  tendency  in  the 
use  of  all  stimulants  is  to  exceed  a  healthful  limit.  Condiments,  as 
well  as  other  stimulants,  should  be  used  in  moderation. 

COOKING. 

Much  more  attention  than  is  generally  given  should  be  paid  by 
physicians  to  the  culinary  art.  The  manner  in  which  food  is  cooked 
has  no  little  influence  upon  its  digestibility.  There  can  be  no  question 
that  the  extreme  prevalence  of  functional  indigestion  in  this  country 
is  almost  exclusively  dependent  upon  bad  cooking. 

The  various  methods  of  cooking  are  boiling,  frying,  roasting, 
broiling,  and  baking.  By  either  of  these  methods  food  can  be  cooked 
so  as  to  be  palatable  as  well  as  digestible;  on  the  other  hand,  the 
choicest  article  can  be  utterly  spoiled  and  rendered  unfit  to  be  taken 
into  the  human  stomach.  It  depends,  therefore,  not  so  much  upon 
the  method  of  cooking,  as  upon  the  knowledge  and  art  of  the  cook. 

Boiling. — ]\Ieats  of  all  kinds  are  rendered  tender  and  digestible 
by  boiling.  In  order  to  retain  the  flavor  of  meat,  the  water  should  be 
boiling  when  the  meat  is  put  into  it.  By  the  heat  of  the  boiling  water 
the  albumin  on  the  outside  of  the  meat  is  coagulated  and  the  juices 
and  flavor  are  retained  within.  After  a  few  minutes  the  temperature 
of  the  water  should  be  reduced  to  71°  to  77°  C.  (160°  to  170°  F.),  and 
maintained  at  that  height  until  the  meat  is  tender.  By  this  process 
a  much  more  savory  piece  of  beef,  mutton,  or  fowl  can  be  obtained 
than  where  the  meat  is  put  into  cold  water  and  thus  gradually  heated. 
The  latter  m.ethod  is,  however,  the  proper  one  to  be  followed  when 
good  soup  or  broth  is  desired. 

In  boiling  vegetables,  as  much  care  is  necessary  as  in  boiling 
meat  or  fish.  Potatoes  and  rice  should  be  steamed,  rather  than 
boiled. 

The  difiiculty  of  obtaining  a  good  cup  of  coffee,  especially  in  the 
northern  part  of  the  United  States,  illustrates  the  prevailing  ignor- 
ance upon  one  of  the  simplest  points  in  the  art  of  cooking.     Coffee 


COOKING.  137 

should  never  be  served  in  the  form  of  a  decoction ;  that  is  to  say,  it 
should  never  be  boiled.  Properly  made  it  is  an  infusion,  like  tea, 
which  no  one  ever  thinks  of  boiling.  The  difference  between  an  in- 
fusion (especially  if  made  by  percolation)  and  a  decoction  of  coffee 
can  only  be  appreciated  by  those  who  have  enjoyed  the  one  and  en- 
dured the  other. 

Frying. — Frying,  if  properly  done,  is  really  nothing  less  nor 
more  than  boiling  in  oil  or  fluid  fat  of  some  kind.  Olive-oil  is  pre- 
ferable, but  is  not  essential;  butter,  beef-drippings,  lard,  or  probably 
cotton-seed  oil  may  be  substituted  for  it  without  disadvantage.  The 
principle  of  frying  depends  upon  the  fact  that  the  temperature  of  oil 
can  be  raised  to  such  a  height  as  to  produce  instant  coagulation  on 
the  surface  of  meat,  fish,  or  other  objects  immersed  in  it  while  hot; 
this  film  of  coagulated  albumin  imprisons  the  juices  and  flavors  of 
the  meat  or  fish,  and  prevents  the  fat  entering  and  soaking  the  fibers 
with  grease.  Small  fish  or  birds,  properly  fried,  are  justly  regarded 
as  delicacies  by  connoisseurs,  but  the  process  of  saturating  these  ob- 
jects with  fat  while  gradually  heating  them  produces  a  dish  that 
is  anything  rather  than  grateful  to  the  palate,  or  conducive  to  good 
digestion. 

Roasting. — The  fame  of  the  "roast  beef  of  Old  England"  has 
passed  into  song,  but,  at  the  present  day,  beef  and  other  meats  are 
rarely  roasted,  either  in  this  country  or  abroad.  As  Sir  Henry 
Thompson  well  expresses  it,^^  '^the  joint,  which  formerly  turned  in 
a  current  of  fresh  air  before  a  well-made  fire,  is  now  half  stifled  in 
a  close  atmosphere  of  its  own  vapors,  very  much  to  the  destruction  of 
the  characteristic  flavor  of  a  roast."  It  is  probable  that  the  old  method 
of  roasting  before  an  open  fire  produced  not  only  the  most  savory, 
but  likewise  the  most  nutritious  and  digestible,  meat.  It  is  to  be 
much  regretted  that  the  process  has  fallen  so  greatly  into  disuse. 

Broiling  and  Baking. — These  methods  of  cooking  are  modifica- 
tions of  the  process  of  roasting.  Meats  or  fish,  carefully  broiled  or 
baked,  preserve  their  natural  juices  and  flavors  to  a  great  extent,  and 
retain  their  digestibility  and  nutritions  properties.  Of  all  methods 
of  cooking  these  are  probably  the  best  known  and  most  satisfactorily 
applied  in  this  country.^*' 

"Food  and  Fepding,  p.  45.    London,  1880. 

"Every  one  intcrostfd  in  the  proper  anplieation  of  the  principles  of  cook- 
ery should  study  the  Lomb  prize  essay  of  the  American  Public  Health  Asso- 
ciation, by  Mary  Hinman  Abel,  upon  "Practical,  Sanitary,  and  Economic  Cook- 
in<^."  This  little  book  can  be  ol)tained  of  Dr.  T.  A.  Watson.  Secretary,  Concord, 
N.  H. ;  price,  2.5  cents.  See,  also,  an  essay  on  "The  Art  of  Cooking,"  by  Edward 
Atkinson,  LL.I).,  in  Popular  Science  Monthly,  November,  1889. 


138  TEXT-BOOK  OF  HYGIENE. 

ALIMENTARY  BEVERAGES. 

The  alimentary  beverages  may  be  c'ivided  into  two  classes, — 
those  depending  for  their  effect  npon  the  alcohol  they  contain,  and 
those  whose  active  principles  reside  in  certain  alkaloids.  They  are 
used  chiefly  as  digestive  and  nervous  stimulants. 

BEVERAGES  CONTAINING  ALCOHOL. 

The  physiological  action  of  alcohol  has  been  pretty  fully  worked 
out  by  Binz  and  his  pupils,  and  by  other  experimenters.  From  these 
researches,  it  appears  that  the  first  effect  of  taking  alcohol,  sufficiently 
diluted,  into  the  stomach  is  to  increase  the  flow  of  the  saliva  and  gas- 
tric juice.  This  effect  is  probably  reflex,  and  results  from  a  stimulation 
of  nerve  terminations  in  the  stomach.  The  alcohol  is  rapidly  absorbed, 
and  is  carried  in  the  blood,  without  undergoing  chemical  change,  to  the 
nervous  centres,  lungs,  and  tissues  generally.  In  the  brain  the  alcohol 
probably  enters  into  combination  with  the  nervous  tissue,  modifying 
the  normal  activity  of  the  various  centres,  either  increasing  the 
activity,  if  the  alcohol  is  in  small  quantity  (stimulating  effect),  or 
diminishing  it  if  in  larger  quantity  (depressing  effect),  or  entirely 
suspending  the  activity  of  the  centres,  if  in  sufficiently  large  quantity 
(paralyzing  effect). 

Alcohol  stimulates  the  vasodilator  nerves,  causing  dilatation  of 
the  smaller  vessels ;  in  consequence  of  this  the  blood  is  largely  sent  to 
the  periphery  of  the  body;  the  blood-pressure  diminishes,  and  heat- 
radiation  is  increased.  At  the  same  time  a  portion  of  the  alcohol  is 
used  up  in  the  lungs  in  the  production  of  animal  heat,  thus  econom- 
izing the  expenditure  of  fats  and  proteid,  and  acting  as  a  true  re- 
spiratory food.  Alcohol  does  not  contribute  nutritive  material  to 
the  body;  it  only  permits  that  which  is  stored  up  to  be  saved  for 
other  uses,  by  furnishing  easily-oxidizable  (combustible)  material  for 
carrying  on  the  respiratory  process,  and  supplying  animal  heat. 

During  the  use  of  alcohol  the  excretion  of  urea  is  diminished. 
This  shows  that  waste  of  tissue  is  retarded  in  the  body. 

Eegarding  the  statement  of  some  authorities  that  alcohol  does  not 
undergo  any  change  in  the  body,  but  is  excreted  unchanged,  Binz 
asserts^''  that  alcohol  appears  in  the  urine  only  when  exceptionally 
large  quantities  have  been  taken,  and  then  in  very  small  proportion. 
It  is  not  excreted  by  the  lungs,  the  peculiar  odor  of  the  breath  being 

"  Realencyclopsedie  d.  ges.  Heilk.,  Bd.  I,  p.  183. 


BEVERAGES  CONTAINING  ALCOHOL.  139 

due  not  to  the  alcohol,  but  to  the  volatile  aromatic  ether,  which  is 
oxidized  with  greater  difficulty,  and  so  escajoes  unchanged. 

While  alcohol  produces  subjectively  an  agreeable  sensation  of 
warmth  in  the  stomach  and  on  the  surface  of  the  body,  the  bodily 
temperature  is  not  raised.  The  subjective  sensation  is  due  to  the 
dilatation  of  the  blood-vessels  and  the  sudden  hyperaBmia  of  those 
parts. 

During  fevers  and  other  exhausting  diseases,  alcohol  is  invaluable 
to  prevent  waste  of  tissue  and  sustain  the  strength.  It  does  not  act 
merely  as  a  stimulant  to  the  circulation  and  nervous  system,  but,  as 
above  pointed  out,  saves  the  more  stable  compounds  by  furnishing  a 
readily  oxidizable  respiratory  food. 

When  taken  in  small  doses  by  healthy  persons,  alcohol  dimin- 
ishes the  temperature  by  increasing  heat-radiation.  When  large  quan- 
tities are  taken,  the  bodily  temperature  is  reduced  by  diminishing 
heat  production,  as  well  as  by  increased  radiation.  This  is  shown 
in  the  condition  known  as  dead-drunkenness,  in  which  the  tempera- 
ture is  sometimes  depressed  as  much  as  20°  F.  below  the  normal. 
Cases  in  which  the  temperature  sank  to  75°,  78.8°,  and  83°  F.  have 
been  reported,  with  recovery  in  all  cases. 

In  discussing  the  physiologic  effect  of  alcohol  Dr.  HalP^  makes 
use  of  what  he  regards  as  the  "deadly  parallel"  between  food  and 
alcohol : — 

Food.  Alcohol. 

1.  A  certain  quantity  will  produce        L  A  certain  quantity  will  produce 
a  certain  effect  at  first,  and  the  same    a  certain  effect  at  first,  but  it  requires 
quantity    will     always     produce     the  more  and  more  to  produce  the  same 
same  effect  in  the  healthy  body.  eft'ect  when  the   drug  is   used  habit- 
ually. 

2.  The  habitual  use  of  food  never  2.  When  used  habitually  it  is  likely 
induces  an  uncontrollable  desire  for  to  induce  an  uncontrollable  desire  for 
it,  in  ever  increasing  amounts.  more,  in  ever  increasing  amounts. 

3.  After  its  habitual  use  a  sudden  3.  After  its  habitual  use  a  sudden 
total  abstinence  never  causes  any  de-  total  abstinence  is  likely  to  cause  a 
rangement  of  the  central  nervous  sys-  serious  derangement  of  the  central 
tern.  nervous  system. 

4.  Foods  are  oxidized  slowly  in  the  4.  Alcohol  is  oxidized  rapidly  in  the 
body.  body. 

5.  Foods,  being  useful,  are  stored  5.  Alcohol,  not  being  useful,  is  not 
in  the  body.  stored  in  the  body. 

6.  Foods  are  the  products  of  con-  6.  Alcohol  is  a  product  of  decom- 
structive  activity  of  protoplasm  in  position  of  food  in  the  presence  of  a 
the  presence  of  abundant  oxygen.  scarcity  of  oxygen. 


"  The  .Journnl  of  the  American  Medical  Association,  vol.  xlviii,  No.  5,  1907. 


140  TEXT-BOOK  OF  HYGIENE. 

Food.  Alcohol. 

7.  Foods  (except  meats)  are  formed  7.  Alcohol  is  formed  in^nature  only 
in  nature  for  nourishment  of  living  as  an  eiicretion.  It  is,  therefore,  in 
organisms  and  are,  therefore,  inlier-  common  with  all  excretions,  inher- 
ently wholesome.  ently  poisonous, 

8.  The  regular  ingestion  of  food  is  8.  The  regular  ingestion  of  alcohol 
beneficial  to  the  healthy  body,  but  is  deleterious  to  the  healthy  body, 
may  be  deleterious  to  the  sick.  but    may    be    beneficial    to    the    sick 

(through  its  drug  action). 

9.  The  use  of  food  is  followed  by  9.  The  use  of  alcohol,  in  common 
no  reaction.  with  narcotics  in  general,  is  followed 

by  a  reaction. 

10.  The  use  of  food  is  followed  by  10.  The  use  of  alcohol  is  followed 
an  increased  activity  of  the  muscle  by  a  decrease  in  the  activity  of  the 
cells  and  brain  cells.  muscle  cells  and  brain  cells. 

11.  The  use  of  food  is  followed  by  11.  The  use  of  alcohol  is  followed 
an  increase  in  the  excretion  of  CO2.   by  a  decrease  in  the  excretion  of  CO2. 

12.  The  use  of  food  may  be  followed  12.  The  use  of  alcohol  is  usually 
by  accumulation  of  fat,  notwithstand-  followed  by  an  accumulation  of  fat 
ing  increased  activity.  through  decreased  activity. 

13.  The  use  of  food  is  followed  by  13.  The  use  of  alcohol  may  be  fol- 
a  rise  in  body  temperature.  lowed  by  a  fall  in  body  temperature. 

14.  The  use  of  food  strengthens  14.  The  use  of  alcohol  weakens  and 
and  steadies  the  muscles.  unsteadies  the  muscles. 

15.  The  use  of  food  makes  the  15.  The  use  of  alcohol  makes  the 
brain  more  active  and  accurate.  brain  less  active  and  accurate. 

The  constant  use  of  alcohol  produces  in  all  the  organs  an  excess 
of  connective  tissue,  followed  by  fatty  degeneration  and  the  condition 
known  as  cirrhosis.  The  organs  most  frequently  affected  are  the 
stomach,  liver,  and  kidneys.  Serious  pathological  alterations  also 
occur  in  the  circulatory,  respiratory,  and  nervous  systems. 

Alcohol  is  not  necessary  to  persons  in  good  health.  Probably 
most  persons,  regardless  of  their  state  of  health,  do  better  without  it. 
Its  habitual  use  in  the  form  of  strong  liquors  is  to  be  unreservedly 
condemned.  The  lighter  wines  and  malt  liquors,  if  obtained  pure, 
may  be  consumed  in  moderate  quantities  without  ill  effects.  Even 
in  these  forms,  however,  the  use  of  alcohol  should  be  discouraged  or, 
perhaps,  prohibited  in  the  young. 

Neither  in  hot  nor  in  cold  climates  is  alcohol  necessary  to  the 
preservation  of  health,  and  its  moderate  use  even  produces  more  in- 
jury than  benefit.  The  Polar  voyager  and  the  East  Indian  mer- 
chant are  alike  better  off  without  alcohol  than  with  it. 

,  It  has  long  been  a  prevalent  belief  that  the  use  of  alcohol  enables 
persons  to  withstand  fatigue  better  than  where  no  alcohol  is  used. 


BEVERAGES  CONTAINING  ALCOHOL. 


141 


A  large  amount  of  concurrent  testimony  absolutely  negatives  this 
belief.^'' 

The  predisposition  to  many  diseases  is  greatly  increased  by  the 
habitual  use  of  alcohol.  Sun-stroke,  the  acute  infectious  diseases,  and 
many  local  organic  affections  attack,  by  preference,  the  intemperate. 
A  recent  collective  investigation  by  the  British  Medical  Association 
brought  out  the  fact  that  croupous  pneumonia  is  vastly  more  fatal 
among  the  intemperate  than  among  those  who  abstain  from  the  use 
of  alcoholic  liquors. 

A  further  investigation  by  Baer  has  shown  that  the  average  ex- 
pectation of  life  among  users  and  dealers  in  alcoholic  liquors  is  very 
much  shortened.  The  following  table  gives  a  comparative  view  of  the 
expectation  of  life  in  those  who  abstained  from  and  those  who  used 
alcohol : — 

Table  XXII. 

EXPECTATION    OF    LIFE. 


Age. 

Abstainers. 

Alcohol  Users. 

At  25 

32.08  years. 

25.92       " 

19.92      " 

14.45       " 

9.62       " 

26.23  years 
20.01       " 

"35 

"45 

15.19       " 

"55 

"65 

11.16       " 
8.04       " 

Table  XXIII  shows  the  influence  of  alcohol  upon  the  mortality 
from  various  diseases : — 


Table  XXIII. 


General  Male  Popu- 
lation (per  cent.). 

Alcohol  Venders 
(per  cent.). 

Brain  disease      

Tuberculosis 

Pneumonia  and  pleuritis      .... 

Heart  disease 

Kidney  disease 

Suicide 

Cancer  

11.77 
30.36 
9.63 
1.46 
1.40 
2.99 
2.49 
22.49 

14.43 
36.57 
11.44 
3.29 
2.11 
4.02 
3.70 

Old  age      .               

7.05 

"See  Parkes'  Hygiene,  6th  ed.,  vol.  i,  pp.  .315-327. 


142  TEXT-BOOK  OF  HYGIEKE. 

Alcohol  as  a  beverage  is  consumed  in  the  various  forms  of 
spirits,  wines,  and  fermented  liquors.  The  varieties  of  spirits  most 
frequently  used  are  brandy,  whisky,  rum,  and  gin.  They  are  all 
procured  by  distillation. 

Brandy  is  distilled  from  fermented  grape-juice,  and  has  a  char- 
acteristic aromatic  flavor.  When  pure  and  m.ellowed  with  age  it  is 
the  most  grateful  to  the  palate  of  all  distilled  spirits. 

Whisky  is  distilled  from  barley,  rye,  oats,  corn,  or  potatoes. 
Each  of  these  has  a  peculiar  flavor,  depending  upon  the  particular 
volatile  ether  formed  during  the  distillation.  Eye-,  barley-,  and  corn- 
whiskies  are  almost  exclusively  used  in  this  country. 

Eum  is  distilled  from  molasses,  and  is  a  favorite  ingredient  in 
hot  punches.  It  is  often  used  with  milk,  eggs,  and  sugar,  in  the  prepa- 
ration of  eggnog,  a  highly  nutritious,  stimulating  drink,  which  is 
often  prescribed  with  great  benefit  in  acute  and  chronic  wasting  dis- 
eases. 

Grin  is  an  ardent  distilled  spirit,  flavored  with  oil  of  juniper. 
It  has  a  widely-spread  popular  reputation  as  a  cure  for  kidney  dis- 
eases, but  is  probably  oftener  responsible  for  the  production  of  these 
diseases  than  for  their  cure. 

All  of  the  above-mentioned  liquors  contain  from  40  to  60  per 
cent,  of  alcohol,  and  should  always  be  diluted  before  being  taken  into 
the  stomach,  in  order  to  prevent  the  local  irritant  effects  of  tbe  alco- 
hol upon  the  gastric  mucous  membrane. 

Wine  is  the  product  of  the  alcoholic  fermentation  of  the  sac- 
charine constituents  of  fruits.  Wine  is  usually  derived  from  the 
grape,  though  other  fruits  may  also  furnish  it.  The  stronger  wines 
(sherry,  port,  maderia)  contain  from  16  to  25  per  cent,  of  alcohol. 
The  lighter  wines  (hock,  red  and  white  Bordeaux  and  Burgundy 
wines,  champagnes)  contain  from  6  to  15  per  cent,  of  alcohol.  Some 
also  contain  considerable  free  carbonic  acid  (sparkling  wines),  of 
which  the  champagnes  are  types.  The  red  and  white  Bordeaux  and 
Ehine  wines  are  probably  the  least  objectionable  of  these  beverages 
for  habitual  use.  They  contain  sufficient  alcohol  to  be  lightly  stim- 
ulant, have  a  pleasant  acid  flavor,  and  are  least  likely  to  produce 
the  bad  effects  which  usually  follow  in  the  wake  of  the  habitual  use 
of  the  stronger  wines  or  ardent  spirits. 

Preference  should  be  given  to  the  wines  of  domestic  manufacture, 
on  account  of  the  great  probability  of  adulteration  of  the  favorite 
brands  of  foreign  wines.    Many  of  the  California,  Virginia,  New  York, 


BEVERAGES  CONTAINING  ALCOHOL.  143 

and  Ohio  wines  compare  very  favorably  in  flavor  with  those  imported 
from  abroad.  The  more  reasonable  cost  of  these  domestic  wines  is 
also  a  point  in  their  favor. 

Cider  is  the  fermented  juice  of  apples.  It  frequently  produces 
unpleasant  gastric  and  intestinal  disturbances  when  drunk,  on  ac- 
count of  the  large  quantity  of  malic  acid  contained  in  it.  Although 
it  is  usually  ranked  as  a  "temperance  drink/'  it  is  quite  capable  of 
causing  intoxication  when  consumed  in  large  quantities. 

Beer  is  the  fermented  extract  of  barley,  mixed  with  a  decoction 
of  hops  and  boiled.  It  should  be  prepared  only  of  malt,  hops,  yeast, 
and  water,  and  should  contain  from  3  to  4  per  cent,  of  alcohol,  5  to 
6  per  cent,  of  extract  of  malt  and  hops,  2  to  4  per  cent,  of  lactic  and 
acetic  acids,  and  from  ^/^  to  ^/o  per  cent,  of  carbonic  acid.  This  ideal 
is,  however,  rarely  attained  in  the  article  sold  by  the  liquor  dealer. 
Numerous  adulterations  are  practiced  on  the  unsuspecting  con- 
sumer. The  hops  are  frequently  substituted  by  aloes,  calamus,  and 
ginger,  or  by  the  more  deleterious  picric  acid  or  picrotoxin.  The 
rich  brown  color,  sweetness,  body,  and  creamy  foam  are  produced  by 
caramel  and  glycerin.  The  more  expensive  barley-malt  is  substituted 
by  starch  and  rice,  or  grape-sugar  and  molasses. 

Ale,  porter,  and  brown-stout  are  merely  varieties  of  beer — some 
containing  more  sugar,  others  more  extractive  matter. 

Beer  and  its  correlatives  have  considerable  dietetic  value,  owing 
not  merely  to  the  alcohol  they  contain,  but  largely  to  the  sugar  and 
acids  entering  into  their  composition.  When  used  to  excess  they  often 
cause  a  considerable  accumulation  of  fat. 

Kumys  is  the  national  beverage  of  the  nomadic  tribes  of  Tar- 
tary.  It  consists  of  the  milk  of  mares  which  has  undergone  fermen- 
tation, partly  lactic  and  partly  alcoholic  in  character.  Eecently  it 
has  been  introduced  into  Europe  and  also  into  this  country,  where 
it  is  made  of  cows'  milk.  It  is  a  palatable,  nutritious  stimulant,  and 
is  often  very  useful  as  a  dietetic  article  in  disease.  Kumys  may  be 
prepared  according  to  the  following  formula:  To  one  pint  of  fresh 
milk  add  one  tablespoonful  of  sugar  and  ^/g  cake  of  compressed  yeast. 
Put  in  bottle  with  patent  stopper,  place  in  warm  room  or  near  the 
stove  for  6  to  12  hours,  then  cool  on  ice  and  serve.  Kumys  has  proved 
a  very  valuable  agent  in  the  treatment  of  gastro-intestinal  diseases. 

Kefyr  is  a  product  of  the  fermentation  of  milk  which  bears  some 
resemblance  to  kumys.  The  following  table  (Table  XXIV)  gives  a 
comparative  view  of  the  composition  of  true  kumys,  the  same  prepared 
from  cows'  milk,  and  kefyr: — 


144 


TEXT-BOOK  OF  HYGIENE. 
Table  XXIV. 


True  Kumys 

Cows'  MilkKumys 

Kefyr 

(percent.). 

(percent.). 

(percent.) 

Pi'oteids 

2.20 

2.35 

3.12 

Fats 

2.12 

2.07 

1.95 

Sugar 

1.53 

1.81 

1.62 

Lactic  acid 

0.90 

0.40 

0.83 

Alcohol 

1.72 

1.90 

2.10 

CO2 

0.85 

0.80 

0.92 

As  bearing  on  the  question  of  intemperance,  it  may  be  well  to 
mention  that  many  patent  medicines  which  are  largely  consumed 
by  the  laity  for  their  supposed  curative  effect  owe  their  virtues  to  the 
large  amounts  of  alcohol  which  they  contain.  The  following  is  a  list 
of  the  more  popular  tonics,  analyzed  principally  by  the  Massachu- 
setts State  Board  of  Health : — 


Table  XXV. 

Alcohol, 
Per  cent. 

Liebig  Company's  Cocoa  Beef  Tonic 23.2 

Schenck's  Seaweed  Tonic,  "entirely  harmless" 19.5 

Atwood's  Quinine  Tonic  Bitters 29.0 

Boker's    Stomach   Bitters 42.6 

Burdock  Blood  Bitters    25.2 

Copp's  White  Mountain  Bitters^  "not  an  alcoholic  beverage" . .     6.0 
(It  should  be  noticed  that  this  "tonic"  contains  more  alcohol 
than  the  strongest  beer.) 

Drake's   Plantation    Bitters 33.2 

Green's   Nei-\'ura    17.2 

Hoofland's  German  Bitters,  "entirely  vegetable  and  free  from 

alcoholic  stimulant"   25.6 

Hostetter's  Stomach  Bitters 44.3 

Kaufmann's  Sulphur  Bitters,  "contains  no  alcohol" _  20.5 

(As  a  matter  of  fact  no  sulphur  was  found  in  this  prepara- 
tion.) 

Paine's  Celery  Compound   21.0 

Walker's  Vinegar  Bitters,  "contains  no  spirit" 6.1 

Warner's  Safe  Tonic  Bitters , .  .  35.7 

Ayer's  Sarsaparilla   26.2 

Hood's  Sarsaparilla   18.8 

Dana's  Sarsaparilla  13.5 

Peruna    28.0 

Warner's   Safe  Cure    15.60 

Kilmer's  Swamp  Root   10.90 

Toneco  Stomach  Bitters 35.50 

Angostura  Bitters   50.17 


THE  ALKALOIDAL  BEVERAGES.  145 

The  dose  recommended  on  the  labels  is  from  a  teaspoonful  to  a 
winegiassful  from  one  to  four  times  a  day,  "increased  as  needed." 

The  pure  food  law  recently  enacted  by  our  national  government 
requires  the  amount  of  alcohol  in  a  medicinal  preparation  to  be  plainly 
stated  on  the  label.  Whether  this  will  remove  the  existing  evil  of  sell- 
ing alcohol  under  the  guise  of  medicine  remains  to  be  seen. 


THE    ALKALOIDAL   BEVERAGES. 

The  virtues  of  the  alkaloidal  beverages  depend  upon  certain 
alkaloids  which  differ  very  little  in  their  chemical  composition  or 
physiological  effects,  and  upon  certain  volatile  aromatic  constituents 
of  the  various  articles  used.  The  principal  articles  employed  in  the 
preparation  of  these  beverages  are  coffee,  tea,  chocolate,  mate,  and 
coca.  It  is  estimated  that  500,000,000  people  drink  coffee,  100,000,000 
tea,  50,000,000  chocolate,  15,000,000  mate  or  Paraguay  tea,  and 
10,000,000  coca.  All  of  these  are  active  nervous  stimulants  and  re- 
tarders  of  tissue-waste.  They  are  all  liable  to  produce  serious  func- 
tional disturbances  of  the  nervous,  digestive,  and  circulatory  systems 
if  used  to  excess.  Anaemia,  digestive  derangements,  constipation, 
pale,  sallow  complexion,  loss  of  appetite,  disturbed  sleep,  nervous 
headaches,  and  neuralgias  are  the  most  marked  of  these  effects. 

On  the  other  hand,  when  taken  in  moderate  qiTantities,  the  alka- 
loidal beverages  enable  the  consumer  to  withstand  cold,  fatigue,  and 
hunger;  they  promptly  remove  the  sensation  of  hunger,  and  diffuse 
a  glow  of  exhilaration  throughout  the  body. 

Coffee. — Coffee  is  the  ripe  fruit  (seed)  of  the  Caffea  Arabica, 
a  native  of  i\.rabia  and  Eastern  Africa,  but  now  cultivated  in  other 
tropical  regions  of  the  world.  The  fruit  consists  of  two  flat-convex 
beans,  the  flat  surfaces  of  which  are  apposed  to  each  other.  These 
are  enclosed  in  a  fl1)rous  envelope  which  is  sometimes  used  as  a  cheap 
substitute  for  the  coffee-bean. 

The  beverage,  coffee,  is  an  infusion  of  the  roasted  and  ground 
bean  in  hot  water.  Its  virtues  depend  upon  the  alkaloid,  caffein,  and 
an  aromatic  oil.  The  latter,  being  volatile,  is  driven  off  by  long- 
continuod  heat.  Hence  boiled  coffee  lacks  the  grateful  aroma  of  that 
which  is  made  by  simply  infusing  the  ground  bean  in  hot  water. 

The  great  demand  for  coffee  and  its  comparatively  high  price 
have  caused  it  to  be  extensively  adulterated  and  substituted  by  other 
natural  and  artificinl  products.  Artificial  coffee-beans  have  been  made 
of  clay,  dough,  or  extract  of  chicory,  colored  to  imitate  the  natural 

10 


146  TEXT-BOOK  OF  HYGIENE. 

bean.  The  fraud  is  easily  detected  by  placing  the  beans  in  water, 
when  the  artificial  product  soon  falls  to  pieces,  while  the  natural 
beans  undergo  no  change  of  shape  or  consistence. 

Ground  coffee  as  found  in  the  stores  is  usually  adulterated.  The 
materials  used  for  sophistication  are:  The  grounds  of  coffee  previ- 
ously used,  the  roasted  root  of  chicory,  acorns,  rye  or  barley,  carrots, 
sun-flower  seeds,  caramel,  and  a  number  of  articles  of  similar  value, 
genei'ally  harmless. 

Tea.- — The  plants  which  furnish  the  tea-leaves  are  natives  of 
China,  Indo-China,  and  Japan.  The  tea-leaves  contain  a  crystalline 
alkaloid,  thein,  identical  in  composition  and  properties  with  caffein. 
The  various  sorts  of  tea  found  in  the  market  (green  and  black  teas, 
etc.)  differ  only  in  the  relative  proportion  of  tannin  and  thein  con- 
tained in  each.  The  aromatic  principle  also  varies  somevrhat  in  the 
different  sorts. 

Tea  is  adulterated  to  quite  as  great  an  extent  as  coffee,  the  leaves 
of  various  plants  bearing  more  or  less  resemblance  to  tea-leaves 
being  added  to  the  latter.  Much  of  the  tea  found  in  the  market  is 
colored  artificially  with  Prussian  blue  and  iron  oxide.  These  addi- 
tions are  harmless,  as  they  are  not  soluble  in  water. 

Chocolate. — Cocoa,  from  which  chocolate  is  derived,  is  widely 
different  in  composition  from  tea  and  coffee.  In  addition  to  its  ac- 
tive principle,  theobromin,  which  is  identical  with  caffein,  it  contains 
nearly  50  per  cent,  of  fat,  which  renders  it  an  article  of  high  nutri- 
tive value. 

Mate,  or  Paraguay  tea,  guarana,  and  coca  are  used  to  a 
considerable  extent  in  some  parts  of  South  America  as  substitutes 
for  coffee  and  tea.  Their  composition  is  not  well  known,  but  their 
effects  are  believed  to  depend  upon  alkaloidal  principles  similar  to 
caffein  and  thein. 

TOBACCO. 

Closely  connected  with  the  subjects  treated  in  this  chapter  are 
the  effects  of  the  constant  use  of  tobacco  upon  the  human  system. 
The  depressing  effects  of  tobacco,  due  principally  to  the  nicotine,  upon 
the  nervous  and  digestive  systems  have  long  been  recognized.  Ee- 
cently,  however,  it  has  been  found  that  very  serious  symptoms  are 
produced  upon  the  sense  of  vision  by  the  constant  or  excessive  use  of 
tobacco.  A  special  form  of  amaurosis,  termed  tobacco  amaurosis,  has 
been  frequently  noticed  since  attention  was  first  called  to  it  by 
Mackenzie. 


ADULTERATIONS  OF  FOODS.  147 


ADULTERATIONS    OF   FOODS. 

The  adulteration  of  food-products  has  received  considerable 
attention  of  late,  no  more,  however,  than  the  seriousness  of  the  sub- 
ject demands.  There  is  hardly  a  food-product  which  is  not  sophisti- 
cated by  the  unscrupulous  manufacturer,  and,  while  most  of  the 
adulterants  are  harmless,  many  are  injurious  to  health.  The  follow- 
ing list  from  Battershall  gives  an  adequate  idea  of  the  common  adul- 
terations. As  to  the  uncommon  adulterants,  they  include  such  pal- 
atable substances  as  sawdust,  horseliver,  oak-bark,  colored  earths,  fac- 
tory sweepings,  brick-dust,  and  numerous  others  which  the  ingenuity 
of  the  manufacturer  suggests,  and  which  baffle  all  efforts  at  detection, 
owing  to  their  uncommonness.     The  regular  list,  then,  includes: — 

„  ,            ,       .  f  Starch, 

Bakers    chemicals    <    . , 

Bread  and  flour \  ^ther  meals, 

>•  Alum. 

r  Water, 
Butter     <  Coloring  matter, 

'  Oleomargarine   and   other   fats. 

ri  1  £      1  f  Metallic  poisons. 

Canned  foods   <  \ 

(  Preservatives, 

f  Lard, 

I  Oleomargarine, 
^^''"^^^ j  Cottonseed  oil, 

I  Metallic  salts. 

(  Sugar, 
Cocoa  and  chocolate <  Starch, 

i  Flour. 

f  Chickory, 

j  Peas, 
Coffee    ]  Rye, 

I  Corn, 
•  [  Coloring  matter. 

C  Starch-sugar, 

I  Starch, 
Artificial  essences, 
Poisonous  pigments, 

I  Terra  alba, 

[  Plaster-of-Paris. 

Honey /Glucose  syrup, 

<-  Cane-sugar. 

f  Artificial   glucose, 

I  Bitters, 

^■^^^  l^l"*^""^   I  Sodium  bicarbonate. 

Salt. 


Confectionery     -| 


148  TEXT-BOOK  OF  HYGIENE. 

!  Water, 
Removal  of  fat, 
Presen'atives. 
(Flour, 
Turmeric, 
Cayenne  pepper. 

Olive  oil  (Cottonseed  oil, 

I  Other  oils. 

Pepper    Various  gioimd  meals. 

Pickles    Salts  of  copper. 

(Pepper  dust, 
Starch, 
Flour. 
'  Water, 
Fusel- oil, 

'  ^  '   Aromatic  ether. 

Burnt  sugar. 

Sugar    Starch-sugar. 

r  Exhausted  tea-leaves, 
Foreign  leaves, 
Indigo, 
Tea    \  Prussian  blue. 


Gypsum, 

Soapstone, 

Sand. 


r  Water 
^i^^g^^    (sulphuric  acid. 

r  Water, 
w-  Spirits, 

^^^  )  Coal-tar   and    vegetable    colors, 

I  Factitious  imitations. 

Of  61  samples  of  milk  purchased  of  milk-dealers  in  the  city  of 
Wilmington  and  examined  by  the  Delaware  State  Board  of  Health 
Laboratory,  39  contained  formalin,  12  were  skimmed,  3  were  watered, 
5  were  skimmed  and  watered,  and  2  were  suspicious. 

The  superficial  observer  will  probably  conclude  that  adulteration 
is  accidental  and  irregular;  that  it  depends  entirely  on  the  honesty 
and  business  integrity  of  the  individual  manufacturer.  This  is  far 
from  being  the  case.  Sophistication  is  an  economic  factor  in  the 
struggle  for  trade.  Cheaper  products  are  demanded  by  the  poor, 
and  cheaper  products  are  supplied;  but  as  the  only  way  to  cheapen 
them  is  to  sophisticate,  adulteration  is  practiced  as  a  bona  fide  busi- 
ness measure.  As  a  result,  we  have  fraud  reduced  to  a  system; 
fraud  not  regulated  by  conscience  or  principles;  fraud  from  which 
the  otherwise  honest  man  does  not  shrink,  but,  nevertheless,  fraud 


ADULTERATIONS  OF  FOODS.  149 

which  robs  the  poor  man  of  the  money  he  earns  by  the  sweat  of  his 
brow. 

This  fact  has  been  clearly  brought  out  by  the  Senate  Committee 
appointed  to  investigate  the  extent  and  nature  of  adulteration  of 
foods  (Senate  Report,  Vol.  3,  No.  516).  "The  adulteration  of  pre- 
pared or  manufactured  foods/'  says  the  committee,  "is  very  exten- 
sively practiced,  and  in  many  cases  to  the  great  discredit  of  our  man- 
ufacturers. It  is  only  fair  to  say,  however,  that  a  large  proportion 
of  the  American  manufacturers  who  are  engaged  in  adulterating 
food-products  do  so  in  order  to  meet  competition,  and  it  is  the  ex- 
pression of  those  gentlemen  to  say :  'We  would  be  glad  to  get  out  of 
the  business  of  adulterating.  We  would  like  to  quit  putting  this  stuff 
in  our  coffee,  and  would  be  willing  to  brand  our  syrups  for  what  they 
are,  but  our  competitors  get  a  trade  advantage  which  we  cannot  sur- 
render.' " 

In  a  recent  report  of  the  Illinois  State  Pood  Commission  (1899- 
1900)  we  find  the  following  table  of  adulterations  detected  during  the 
year : — 

Table  XXVI. 

Number  Number 

Article    of    Food.  Analyzed.      Adulterated. 

Baking  powder   44  44 

Butter    49  36 

Catsup    47  45 

Cider  (apple)    3  1 

Cider  (orange)   1  1 

Coffee  15  0 

Condensed  milk  (bulk) 4  1 

Condensed  milk  (cans) 22  4 

Cream  of  tartar 11  2 

Honey    '. 22  9 

Jellies,   Jams,   etc 13  9 

Lemon  extracts 34  27 

Milk    29  5 

Olive  oil 25  13 

Sugar   (granulated)    1  1 

Vanilla  extract   26  20 

Vinegar   360  192 

Total    712  412 

The  recently  enacted  pure  food  law  will  remedy  the  evil  of  mis- 
branding so  far  as  interstate  commerce  goes,  but  will  not  prevent 
adulteration  of  foods  and  food-products  within  the  limits  of  any 
single  State.  State  legislation  will  be  required  to  meet  these  condi- 
tions in  each  State. 


150  TEXT-BOOK  OF  HYGIENE. 


THE    EXAMINATION    OF   FOOD. 

It  wonld  be  manifestly  inadvisable  to  attempt  to  detail  tlie 
methods  for  the  determination  of  the  purity  and  healthfiilness  of  the 
many  articles  of  food  that  make  up  the  daily  dietaries  of  the  people 
at  large;  but  since  occasions  are  constantly  arising  when  it  is  desir- 
able to  laiow  something  of  the  condition  of  certain  food-stufPs  which 
are  used  by  practically  every  one,  and  which  are  especially  liable  to 
sophistication  or  adulteration,  the  following  notes  are,  therefore, 
added  as  being  within  the  scope  of  the  chapter: — 

Milk. — Good  milk  shoukl  be  ivory-white  in  color,  opaque,  of 
neutral  or  slightly-alkaline  reaction,  and  should  have  no  sediment  nor 
any  unusual  taste  or  odor.  The  specific  gravity  should  be  1029  or 
above;  the  proportion  of  cream,  from  10  to  40  per  cent,  by  volume; 
the  fats,  3  per  cent,  or  more,  and  the  total  solids  12.5  per  cent,  or 
more.  The  number  of  bacteria  should  not  exceed  500,000  per  cubic 
centimetre. 

The  color  is  enriched  by  a  high  percentage  of  cream,  but  too 
rich  a  color  or  one  with  a  reddish  or  yellowish  tint  may  indicate  the 
addition  of  annatto.  A  poor  color  indicates  that  the  milk  is  deficient 
in  fat,  and  may  be  due  to  skimming  or  watering,  or  both,  but  a  pecu- 
liar blue  color  is  sometimes  produced  by  the  growth  of  a  certain  fungus 
in  the  milk.  The  lessening  of  fat  also  tends  to  make  the  milk  trans- 
lucent and  less  opaque. 

An  acid  reaction,  unless  very  slight,  indicates  "souring"  of  the 
milk  or  the  addition  of  some  preservative,  such  as  salicylic  or  boric 
acid ;  while  a  strongly-alkaline  reaction  points  to  the  addition  of  some 
substance  like  chalk,  sodium  carbonate,  etc.,  to  increase  the  specific 
gravity.  Such  addition  is  verified  by  a  high  percentage  of  total  solids 
and  by  the  effervescence  of  the  latter  upon  the  addition  of  a  drop  or 
two  of  hydrochloric  acid. 

The  specific  gravity  is  determined  by  means  of  the  lactometer, 
in  using  which  corrections  must  be  made  for  the  temperature  if  the 
latter  varies  much  from  60°  F.,  the  standard.  The  specific  gravity 
is  slightly  raised  by  skimming  the  milk,  since  the  cream  is  lighter 
than  the  whole  milk,  and,  theoretically,  a  very  high  percentage  of 
cream  tends  to  lower  the  specific  gravity;  but,  in  reality,  a  milk  rich 
in  cream  is  also  rich  in  other  solids  that  keep  the  specific  gravity  high 
or,  at  least,  normal. 

The   percentage   of   cream   is    determined   by   the   creamometer, 


THE  EXAMINATIUX  OF  FOOD.  151 

which  should  be  covered  and  in  which  the  milk  should  stand  for  eight 
or  ten  hours. 

The  principal  sophistications  of  milk  are  by  watering,  skimming, 
the  addition  of  solids  to  increase  the  specific  gravity  or  to  act  as  pre- 
servatives or  to  mask  "souring,"  and  the  addition  of  annatto  and  the 
like  to  enrich  the  color.  "Watering  is  indicated  by  a  low  specific 
gravity  and  by  a  low  percentage  of  cream  and  of  total  solids.  Skim- 
ming is  indicated  by  a  low  percentage  of  cream  and  poor  color,  though 
the  latter  m^ay  be  disguised  by  the  addition  of  annatto,  etc.  The  spe- 
cific gravity  will  be  very  slightly  raised  by  the  skimming,  but  if  the 
milk  has  been  both  skimmed  and  watered  the  density  will  be  lowered. 

To  Determine  the  Percentage  of  Total  Solids. — Weigh  a  small 
evaporating  dish,  preferably  platinum.  Add  5  or  10  c.  c.  of  milk,  and 
weigh  the  dish  and  milk  to  get  the  weight  of  milk.  Evaporate  to 
dryness  over  a  water-bath,  completing  the  drying  in  a  water-oven 
until  there  is  no  further  loss  of  weight.  Weigh  the  dish  and  contents 
(total  solids)  ;  subtract  the  weight  of  dish  and  divide  by  the  weight  of 
milk.    The  result  is  the  percentage  of  total  solids. 

To  Determine  the  Percentage  of  Ash. — Ignite  the  tctal  solids 
over  the  naked  flame  until  all  black  specks  have  disappeared.  Cool 
and  weigh.  Divide  the  weight  of  ash  by  weight  of  milk.  The  result 
is  the  percentage  of  ash. 

To  Determine  the  Percentage  of  Fats. — Proceed  as  above  with 
10  c.  c.  of  milk  and  evaporate  till  the  residue  is  a  tenacious  pulp. 
Extinguish  the  flame,  fill  the  dish  half-full  of  ether,  and  stir  and  pound 
the  residue  thoroughly  with  a  glass  rod ;  filter  through  a  small  filter- 
paper,  reserving  the  filtrate ;  add  more  ether  to  the  residue,  stir  as 
before  and  filter,  repeating  the  process  three  times,  or  till  the  residue 
is  perfectly  white.  Wash  filter-paper  well  with  ether,  and  evaporate 
all  the  ether  to  dryness.  Weigh  the  residue  (the  fat)  and  divide  by 
the  weight  of  milk.  Eesult :  percentage  of  fat.  The  fat  can  be  more 
conveniently  determined  by  the  use  of  the  Babcock  tester.  This  is  a 
centrifugal  machine  holding  two  or  more  graduated  bottles  especially 
made  for  this  purpose.  The  test  is  performed  as  follows  :  Measure  17.6 
c.  c.  of  milk  and  an  equal  quantity  of  strong  sulphuric  acid  (sp.  gr. 
1.82)  and  pour  into  the  bottle.  Mix  by  shaking  gently  until  curd  dis- 
solves. Place  in  centrifuge  and  revolve  at  1000  revolutions  per  min- 
ute for  five  minutes.  Pill  the  bottles  to  the  highest  graduation  with 
hot  water  and  whirl  for  one  minute  longer.  Ecad  on  the  scale  the 
space  occupied  by  the  column  of  fat  which  rises  to  the  top.  The  lower 
margin  of  this  column  indicates  the  percentage  of  fat. 


152  ■    TEXT-BOOK  OF  HYGIENE. 

Test  for  Annatto. — A  percentage  of  cream  considerably  lower 
than  color  of  milk  would  indicate  justifies  the  suspicion  that  some 
coloring  matter  has  been  used.  This  is  generally  annatto.  Coagulate 
one  ounce  of  milk  with  a  few  drops  of  acetic  acid,  and  heat ;  strain  and 
press  out  excess  of  liquid  from  curd.  Triturate  the  curd  in  a  mortar 
or  dish  with  ether.  Decant  the  ether  and  add  to  it  10  c.  c.  of  a  1- 
per-cent.  solution  of  caustic  soda.  Shake  and  allow  to  separate;  pour 
off  the  upper  layer  into  a  porcelain  dish.  Put  in  two  small  discs  or 
strips  of  filter-paper.  Evaporate  gently;  annatto  will  dye  the  discs 
an  orange  or  buff  color.  Moisten  one  disc  with  dilute  sodium  carbon- 
ate to  fix  the  color.  Touch  the  other  disc  with  a  drop  of  stannous 
chloride ;  annatto  will  give  a  rich  pink  color.  This  test  is  sensitive  to 
1  part  of  annatto  in  1000  of  milk,  and  with  milk  in  any  condition. 

Detection  of  Cane-sugar  in  Milk  and  Cream. — Mix  15  c.  c.  of 
milk  or  cream  with  .1  gram  resorcin  and  1  c.  c.  cone,  hydrochloric  acid 
and  heat  to  boiling.  In  presence  of  cane-sugar  a  fine  red  color  is  pro- 
duced, while  pure  milk  turns  brownish;  0.2  per  cent,  can  thus  be  de- 
tected.    Levulose  gives  the  same  reaction,  but  glucose  does  not. 

Test  for  Boric  Acid. — In  igniting  the  total  solids,  boric  acid,  or 
boron,  gives  a  greenish  tinge  to  flame.  Place  in  a  porcelain  dish  one 
drop  of  milk,  two  drops  of  strong  hydrochloric  acid,  and  two  of  sat- 
urated tincture  of  turmeric.  Dry  on  a  water-bath,  remove  as  soon  as 
dr}^,  cool  and  add  one  drop  of  ammonia  on  a  glass  rod.  A  slaty-blue 
color,  changing  to  green,  is  given  if  borax  is  present.  This  test  will 
show  ^/looo  grain  of  borax.  Less  will  give  the  green  color,  but  not  the 
blue. 

Formaldehyde. — The  milk  is  diluted  with  an  equal  volume  of 
water.  Sulphuric  acid  containing  a  trace  of  ferric  chloride  is  added 
so  that  it  forms  a  layer  beneath  the  milk.  Under  these  conditions, 
milk,  in  the  ahsence  of  formaldehyde,  gives  a  slight  greenish  tinge  at 
the  juncture  of  the  two  liquids,  while  a  violet  ring  is  formed  when 
formaldehyde  is  present  even  in  so  small  a  quantity  as  1  part  in  200,- 
000  of  miik. 

Sodium  Carhonate. — Ten  c.  c.  of  milk  are  mixed  with  an  equal 
volume  of  alcohol  and  a  few  drops  of  a  1-per-cent.  solution  of  rosolic 
acid  added.  Pure  milk  shows  merely  a  brownish-yellow  color,  but  in 
the  presence  of  sodium  carbonate  a  more  or  less  marked  rose-red  ap- 
pears. This  test  is  made  more  delicate  by  using  a  comparison  cylin- 
der containing  the  same  amount  of  milk  known  to  be  pure. 

Butter. — Good  butter  should  have  a  good  taste,  odor,  and  color; 
it  should  not  be  rancid,  and  should  not  contain  too  much  salt,  nor 


THE  EXAMINATION  OF  FOOD.  153 

should  it  have  any  added  coloring  matter.  The  average  composition 
should  be  about  as  follows :  Fat,  82  per  cent. ;  casein,  2  per  cent, 
(not  over  3  per  cent.)  ;  ash  or  salts,  2  per  cent.;  water,  13  per  cent.; 
milk-sugar,  1  per  cent.  Butter-fat  is  a  compound  of  a  glycerine  with 
certain  fatty  acids,  some  of  them  volatile  and  soluble  in  hot  water, 
others  non-volatile  and  insoluble  in  hot  water. 

Oleo-margarine  consists  of  ordinary  animal  (or  vegetal^le)  fats 
melted,  strained,  cooled  with  ice,  worked  up  with  milk,  colored,  and 
salted.  These  fats  are  usually  beef  or  mutton,  lard  or  cotton-seed, 
palm-  or  cocoa-nut-  oil.  If  care  and  cleanliness  are  observed  in  the 
manufacture,  oleo-margarine  is  not  harmful  or  innutritions,  but  it 
should  not  be  sold  as  butter. 

Fraud  is  to  be  detected  by  observing  the  difference  in  composition 
and  properties  of  the  fats.  The  following  talkie,  from  Kenwood^s 
"Hygienic  Laboratory,"  will  show  the  characteristic  difference  in  the 
fats : — 

Butter-fat.  Beef-fat. 

1.  The     specific     gravity     is     very  Is  never  above  904.5. 
rarely  below  910,  never  below  909.8. 

2.  The  soluble,  volatile  fatty  acids  Rarely  more  than  Vs  per  cent.; 
average  between   6   and   7   per   cent,       never  above  %  per  cent. 

never  below  4.5  per  cent. 

3.  The    insoluble    fatty   acids    form  Generally  about  95  per  cent, 
about  88  per  cent,  of  the  total  weight 

of  butter-fat. 

4.  The    melting-point     of    the    fat  Earely,  if  ever,  above  82°  F. 
varies  from  86°  to  94°  F. ;    is  usually 

from  88°  to  90°  F. 

5.  Is  readily  and  completely  soluble  Less  so,  and  leaves  a  residue, 
in  ether. 

6.  Under  the  microscope  pure  but-  The  contours  of  the  small  oil-glob- 
ter  consists  of  a  collection  of  small  ules  are  less  distinct,  and  the  larger 
oil-globules'  with  an  occasional  large  ones  are  more  numerous  and  irregular 
one.  No  crystals,  except  when  the  in  size.  Crystals  of  the  non-volatile 
fat  has  been  melted.  acids  are  often  seen. 

To  Determine  the  Specific  Gravity. — ]\Ielt  a  quantity  of  the  but- 
ter in  a  beaker  on  a  water-bath  at  about  150°  F.  After  a  time,  when 
the  fat  is  perfectly  clear  and  transparent,  carefully  decant  from  the 
lower  stratum  of  water,  curd  and  salt  on  to  a  fine  filter;  collect  the 
filtrate  and  pour  into  a  specific-gravity  bottle,  which  has  been  previ- 
ously weighed,  both  when  empty  and  when  filled  with  water  at  100°  F. 
See  that  the  bottle  is  exactly  full  of  the  fat;  wipe  clean  and  weigh 
when  the  temperature  is  as  near  100°  F.  as  possible,  because  solidifica- 


154  TEXT-BOOK  OF  HYGIENE. 

tion  soon  begins  at  this  temperature.  Subtract  tbe  weight  of  the 
bottle,  divide>by  the  weight  of  the  water,  and  multiply  by  1000.  The 
result  is  the  specific  gravity. 

To  Find  the  Melting-point. — Pour  a  little  melted  fat  into  a  small 
test-tube  (2"x^/^").  Partly  fill  two  beakers  of  unequal  size  with 
cold  water;  place  the  test-tube  in  the  smaller  (taking  care  to  allow 
no  water  to  mix  with  the  fat),  and  the  smaller  in  the  larger,  and 
gently  heat  the  outer  beaker.  Suspend  a  thermometer  in  the  smaller, 
near  the  test-tube,  and  note  the  temperature  when  the  fat  begins  to 
melt.     This  is  the  melting-point. 

To  Determine  the  Percentage  of  Insoluble  (Non-volatile)  Fatty 
Acids. — To  5  grammes  of  butter-fat  add  50  c,  c.  of  alcohol  contain- 
ing 2  grammes  of  caustic  potash  (KHO)  and  boil  gently  for  fifteen 
or  twenty  minutes  to  saponify  the  fat.  Dissolve  the  soaps  thus  formed 
in  150  to  200  c.  c.  of  water  and  decompose  with  about  25  c.  c.  of  dilute 
hydrochloric  acid.  The  separated  fatty  acids  are  collected  upon  a 
weighed  filter-paper,  washed  with  2  litres  of  boiling  water,  dried  at 
95°  to  98°  C,  and  then  weighed.  The  weight  of  these  insoluble  fatty 
acids  should  not  be  over  90  per  cent,  of  the  weight  of  the  butter-fat. 

Flour  and  Bread. — Wheat-flour  should  be  almost  but  not  per- 
fectly white,  also  smooth  and  free  from  grit;  it  should  have  no  moldy 
or  unpleasant  odor,  and,  imless  made  by  the  new  process,  should  be 
cohesive  when  lightly  compressed  in  the  hand.  There  should  be  no 
signs  of  parasites  or  fungi  under  the  microscope.  The  proportion  of 
gluten  should  be  more  than  8  per  cent. ;  of  water,  less  than  18  per 
cent.,  and  of  ash,  less  than  2  per  cent. 

To  Determine  the  Percentage  of  ^Yater  and  Ash. — In  a  weighed 
platinum  (or  porcelain)  dish  place  about  50  grammes  of  fl.our,  weigh 
and  dry  over  a  water-bath  for  an  hour  or  so ;  then  complete  the  evap- 
oration in  a  water-oven  until  there  is  no  further  loss  of  weight; 
weigh,  subtract  this  weight  less  the  weight  of  the  dish  from  the  orig- 
inal weight  of  the  flour.  The  result  is  the  percentage  of  water.  Then 
igTiite  the  dried  flour  in  the  dish  and  incinerate  till  there  are  no 
longer  any  black  particles  and  only  the  ash  remains ;  cool,  weigh,  and 
divide  by  the  original  weight  of  the  flour.  The  result  is  the  per- 
centage of  ash. 

To  Determine  the  Percentage  of  Gluten. — By  means  of  a  glass 
rod,  mix  a  weighed  quantity  of  flour  with  a  little  distilled  water  into 
a  stiff  dough ;  then  repeatedly  wash  away  the  starch  and  soluble  con- 
stituents, kneading  the  dough  with  the  rod  or  fingers  and  continuing 
"until  the  wash-water  comes  away  clear;  the  gluten  and  a  small  amount 


THE  EXAMINATION  OF  FOOD.  155 

of  fat  and  salts  remain.  Spread  out  on  a  weighed  dish  or  crucible-lid, 
dry  in  a  water-oven,  and  weigh.  Divide  by  the  original  weight  of  the 
flour.  The  result  is  the  approximate  percentage  of  gluten.  The 
gluten  should  pull  out  in  long  threads,  otherwise  it  is  poor. 

An  excess  of  water  impairs  the  keeping-quality  and  lessens  the 
amount  of  nutriment  in  the  flour.  An  excess  of  ash  indicates  the 
addition  of  mineral  substances.  A  deficiency  of  gluten  indicates  that 
the  flour  is  not  pure  wheat-flour.  Parasites  and  fungi  especially  affect 
or  live  in  old  or  damp  and  inferior  flour. 

To  Test  for  Mineral  Substances. — Shake  a  little  flour  in  a  test- 
tube  with  some  chloroform,  and  allow  it  to  stand  for  a  few  mo- 
ments. The  flour  floats  and  any  mineral  matter  sinks  to  the  bottom, 
when  it  can  be  removed  with  a  pipette  and  examined  under  a  micro- 
scope. 

Wheat-bread  should  be  fairly  dry,  light,  and  spongy;  clean  and 
nearly  white;  of  pleasant  taste;  not  sodden,  acid,  or  musty;  no 
parasites  or  moldiness.  It  should  contain  no  flour  other  than  wheat; 
but  little,  if  any,  alum;  no  copper  sulphate;  and  should  not  yield 
over  3  per  cent,  of  ash. 

Test  for  Alum. — Add  5  c.  c.  of  a  5-per-eent.  tincture  of  logwood 
and  5  c.  c.  of  a  15-per-cent.  solution  of  ammonium  carbonate  to  35 
c.  c.  of  water ;  soak  a  crumb  of  the  bread  in  this  for  a  few  minutes ; 
drain  and  gently  dry.  Alum  is  indicated  by  a  violet  or  lavender 
color,  its  absence  by  a  dirty-brown  color  on  drying. 

Test  for  Copper  Sulphate. — Draw  a  glass  rod  dipped  in  a  solution 
of  potassium  ferrocyanide  across  a  cut  slice  of  the  bread;  copper  is 
indicated  by  a  streak  of  brownish-red  color. 

Test  for  Ergot  in  Flour  or  Bread. — Add  liquor  potassse;  a  dis- 
tinct, herring-like  odor  (due  to  propylamine)  is  appreciable  if  ergot 
be  present. 

An  excess  of  water,  an  unnatural  whiteness,  and  a  low  percentage 
of  ash  in  bread  indicate  the  addition  of  rice.  Potatoes  give  an  in- 
creased percentage  of  water  and  an  alkaline  ash. 


QUESTIONS  TO  CHAPTER  III. 

FOOD. 

What  is  a  food?  What  reasons  have  we  for  stating  that  the  proximate 
food  principles  must  be  combined  in  definite  proportions  to  maintain  a  normal 
degree  of  health?  What  are  the  alimentaiy  principles  necessary  to  man's 
existence?  Why  do  we  need  water?  What  are  the  functions  of  the  salts  in 
our  foods?  Is  existence  possible  without  a  sufficient  supply  of  nitrogenous 
food?     What  is  the  relation  of  starch  to  fat  as  oxidizable  food? 

Are  the  proteid  tissues  of  the  body  derived  solely  from  the  nitrogenous 
foods?  \^Tiat  are  the  sources  of  the  body-fat?  What  tissues  are  mostly  con- 
sumed during  work? 

What  is  the  relation  between  the  proximate  food  principles,  and  what 
amount  of  each  is  necessary  in  the  standard  daily  diet  of  a  man  at  rest?  At 
moderate  labor?  At  hard  work?  About  what  is  the  relation  of  nitrogenous 
to  non-nitrogenous  food?  Of  nitrogen  to  carbon?  Is  a  standard  diet  neces- 
sarily an  expensive  one?     How  may  it  be  selected?     What  is  a'  calorie? 

Whj  is  a  variety  in  the  kind  of  food  necessary?  Why  may  not  a  man 
live  on  nitrogenous  foods,  like  meat,  alone?  Why  not  on  non-nitrogenous 
food,  like  potatoes? 

Has  climate  much  influence  upon  the  amount  of  food  needed?  Has  it 
upon  the  kind  of  food?  What  kind  of  food  is  especially  beneficial  for  a  labor- 
ing man  in  cold  weather?  Where  do  we  find  the  proteid  principles  of  food? 
Where  the  fatty?  Where  the  carbohydrates?  The  salts?  Why  should  only 
a  moderate  amount  of  food  be  taken,  and  why  should  it  be  properly  prepared? 
What  are  some  of  the  factors  that  increase  the  consumption  of  carbonaceous 
foods?  Does  increased  physical  labor  increase  the  demand  for  nitrogenous 
foods?  Which  requires  the  most  carbonaceous  food,  physical  or  mental  labor? 
What  maladies  especially  require  fat-producing  foods?  Has  the  food  that  a 
man  eats  anything  to  do  with  his  moral  character? 

How  may  we  classify  food?  Name  some  of  animal  origin.  From  the 
vegetable  kingdom.    What  is  the  function  of  condiments?     Of  stimulants? 

Why  is  milk  so  nearly  a  perfect  food?  "Wliat  is  the  average  composition 
of  cows'  milk?  "\^Tiat  is  the  difference  between  human  milk  and  cows'  milk? 
What  other  substitutes  are  sometimes  used  for  human  milk? 

What  is  cream?  What  changes  take  place  in  milk  upon  standing  for 
some  time?  To  what  are  these  changes  due?  What  is  made  from  the  curd? 
Has  whey,  or  butter-milk,  any  food  value? 

What  should  be  the  specific  gravity  of  milk?  How  is  it  determined? 
What  may  lower  the  specific  gravity?  'VSTiat  may  raise  it?  Has  "skim-milk" 
a  food  value?    What  is  the  objection  to  its  sale? 

(156) 


QUESTIONS  TO  CHAPTER  III.  157 

How  is  milk  frequently  adulterated?  How  may  this  be  detected?  Why 
is  the  addition  of  water  dangerous?  How  else  might  the  milk  become  in- 
fected? 

May  infectious  diseases  be  transmitted  from  the  cow  to  man  through 
the  milk?  How  may  this  danger  of  infection  be  avoided?  What  diseases  are 
especially  likely  to  be  thus  conveyed  by  the  milk?  Give  an  account  of  the 
"Hendon  cow  disease."  May  the  milk  of  animals  suffering  from  certain  febrile 
diseases  be  dangerous  to  health?  Is  the  milk  of  cows  fed  on  distillery  or 
breweiy  refuse  necessarily  unwholesome? 

How  may  the  quality  of  a  milk  be  determined?  What  is  a  lactoscope? 
What  is  a  creamometer?  What,  should  be  the  minimum  percentage  of  cream? 
How  may  the  rapid  fermentation  of  milk  be  prevented?  What  is  tyrotoxicon, 
and  to  what  is  it  due? 

What  is  butter?  What  is  its  food  value,  and  why?  What  change  does 
it  undergo  in  becoming  "rancid"?  How  is  it  often  sophisticated?  What  is 
oleo-margarine  or  butterine?  How  is  it  made?  Is  it  unwholesome,  and  is 
there  any  objection  to  its  use  if  sold  under  its  proper  name?  Upon  what 
does  the  value  of  cheese  depend?  Is  it  nutritious?  Why  cannot  large  quan- 
tities be  eaten  at  a  time? 

What  are  the  richest  kinds  of  cheese?  Is  cheese  often  adulterated?  How 
may  cheese  be  made  more  digestible?  What  dangerous  change  may  it  undergo, 
and  to  what  is  this  due? 

Why  is  meat  such  an  important  article  of  food?  What  is  the  percentage 
of  proteids  and  fats  in  the  meats  commonly  used?  Upon  what  does  the  varia- 
tion between  these  two  principles  depend?  Should  meat  be  cooked  and  eaten 
immediately  after  death?  Should  it  be  kept  too  long  after  death  before  being 
used?  Why  should  meat  be  always  cooked?  \Vhat  are  the  common  methods 
of  cooking?  Are  beef-extracts  really  nutritious?  Are  partially  or  wholly  pre- 
digested  preparations  of  meat  nutritious?  What  is  the  objection  to  their 
continued  use? 

What  conditions  may  render  meat  unfit  for  food?  How  may  the  various 
parasites  in  meat  be  destroyed?  What  animals  are  apt  to  be  infested  with 
trichinae?  In  what  two  forms  are  the  trichinae  found  in  animals?  How  do 
they  gain  access  to  the  muscles?  May  salted  or  smoked  meat  contain  living 
trichinae?    Of  what  parasite  is  the  Cysticercus  cellulosa  a  transition  form? 

What  may  be  the  result  of  using  partially-decomposed  meat  or  fish?  To 
what  are  the  serious  results  due?  How  are  the  ptomaines  produced?  What 
is  their  probable  chemical  nature?  What  peculiar  idiosyncrasy  have  some 
people  regarding  shell-fish?  What  infectious  diseases  may  be  transmitted  to 
human  beings  by  the  consumption  of  infected  meat?  When  and  by  whom 
should  meat  be  inspected? 

Wliy  are  eggs  so  highly  valued  for  food  ?  In  which  form  are  eggs  most 
digestible?    Why  do  eggs  undergo  putrefaction  so  readily? 

What  cereals  are  used  in  making  bread?  What  part  of  the  grain  con- 
tains the  greater  proportion  of  proteids?    Is  all  the  gluten  to  be  found  in  the 


158  TEXT-BOOK  OF  HYGIENE. 

bran?  Which  flours  are  most  nutritious  and  which  most  digestible?  What 
are  some  of  the  characteristics  of  good  bread?  To  what  is  the  porosity  due, 
and  how  is  it  produced?  How  may  the  loss  of  starch  by  fermentation  be 
avoided?  How  is  flour  often  adulterated?  Why  is  alum  added  to  flour?  What 
disease  of  grain  may  be  harmful  to  the  health  of  the  users? 

What  is  the  chief  constituent  of  potatoes  and  rice?  In  what  principle 
are  the  leguminous  foods  especially  rich?  Wherein  is  the  chief  value  of  green 
vegetables?  Wliy  are  fruits  and  nuts  valuable  as  articles  of  diet?  What  rule 
should  be  observed  regarding  the  use  of  condiments? 

Why  should  physicians  know  considerable  about  cooking?  "What  are 
the  various  methods  of  cooking?  What  is  the  eflect  of  boiling  upon  meats? 
What  points  are  to  be  observed  in  the  boiling  of  meat?  In  the  making  of 
soups,  etc.?  What  valuable  principle  is  lost  if  vegetables  are  boiled  too  long? 
What  is  the  secret  in  making  good  coflee?  What  is  frying?  How  should  it 
be  done?  How  should  meats  be  roasted?  Why  are  broiling  and  baking  gen- 
erally satisfactory  processes? 

Into  what  two  classes  may  alimentary  beverages  be  divided?  For  what 
are  those  of  the  second  class  used?  What  is  the  physiological  effect  and  action 
of  alcohol  upon  the  nerve-centres?  Upon  the  circulation?  Is  it  changed  before 
absoi-ption?  Does  it  nourish  the  body?  Does  it  supply  heat?  Does  it  raise 
the  body-temperature?  What  effect  has  it  on  heat-production  and  heat-radia- 
tion? On  tissue  v/aste?  How^  is  it  excreted?  What  eff"ect  have  small  amounts 
of  alcohol  upon  digestion?  What  pathological  changes  are  brought  about  by 
the  constant  use  of  alcohol?  Is  it  necessary  or  beneficial  to  persons  in  good 
health?  Why  is  it  so  valuable  in  fevers  and  wasting  diseases?  Does  it  enable 
persons  to  withstand  fatigue  ?  To  what  diseases  is  the  predisposition  increased 
by  the  habitual  use  of  alcohol?  What  eff"ect  has  it  upon  the  expectation  of 
life  and  upon  the  mortality  from  various  diseases?  If  used  habitually,  what 
forms  should  be  chosen?  What  is  the  difference  between  spirits,  wines,  and 
malt  liquors?  "SATiat  is  brandy?  From  what  is  whisky  made?  How  much 
alcohol  do  the  various  spirits  contain,  and  what  rule  should  be  observed  re- 
garding their  use?  What  percentage  of  alcohol  do  the  various  wines  contain? 
Which  are  the  least  objectionable  for  habitual  use?  What  can  be  said  regard- 
ing the  domestic  wines?  To  what  disturbances  may  cider  give  rise,  and  why? 
From  what  articles  alone  should  beer  be  made?  How  much  alcohol  should  it 
contain?  With  what  substances  is  it  often  sophisticated?  Have  beer,  ale, 
etc.,  a  dietetic  value,  and  why?  What  may  be  the  result  when  beer  is  used 
to  excess?  What  are  kumys  and  kefyr?  Why  are  they  valuable  in  sickness? 
How  much  alcohol  does  each  contain?  Upon  what  do  the  virtues  of  the 
alkaloidal  beverage  depend?  '\^Tiat  are  the  principal  articles  employed  in  their 
preparation?  What  is  the  physiological  action  of  all  these  substances?  "Wliat 
are  some  of  the  effects  if  they  are  used  to  excess?  What  is  their  effect  when 
used  in  moderation?    May  they  be  used  as  substitutes  for  alcohol? 

What  is  coffee,  and  what  alkaloid  does  it  contain?  What  else  does  it 
contain  that  gives  value  to  the  beverage?  How  is  coffee  adulterated,  and  how 
may  fraud  be  detected  ?  What  is  tea,  and  what  alkaloid  does  it  contain  ?  How 
may   it   be   adulterated?      Why   is   cocoa   of   greater   food   value   than   tea   or 


QUESTIONS  TO  CHAPTER  III.  I59 

coffee?  What  is  its  active  principle,  and  what  is  its  relation  to  thein  and 
caffein?  What  is  the  difference  between  cocoa  and  chocolate?  What  are  the 
effects  of  tobacco  upon  the  human  system,  and  to  what  are  they  due? 

What  are  some  of  the  characteristics  of  good  milk?  What  may  affect  its 
color?  Its  reaction?  Its  specific  gravity?  How  is  it  usually  sophisticated  or 
adulterated?  How  is  the  percentage  of  total  solids  determined?  Of  fats? 
V\^hat  would  a  high  percentage  of  ash  indicate  ?  Give  a  test  for  annatto.  For 
boric  acid.     For  formaldehyde. 

What  are  the  characteristics  of  good  butter?  What  is  the  difference 
between  it  and  oleo-margarine  and  similar  compounds?  What  tw^o  kinds  of 
fatty  acids  does  butter-fat  contain?  What  are  some  of  the  distinctions  be- 
tween butter-fat  and  beef-tea  or  mutton-fat?  Plow  is  the  specific  gravity  of 
butter-fat  determined?  The  melting-point?  The  percentage  of  insoluble  fatty 
acids? 

What  are  some  of  the  properties  of  good  wheat-flour?  Of  wheaten 
bread?  How  is  the  percentage  of  gluten  in  flour  determined?  The  presence  of 
added  mineral  substances?  What  does  a  low  percentage  of  gluten  indicate? 
In  what  kind  of  flour  are  parasites,  etc.,  found?  What  is  a  test  for  alum  in 
bread?  Should  bread  contain  any  alum?  What  flours  or  starches  may  be  used 
to  sophisticate  wheat-flour? 


CHAPTER  IV. 

SOIL. 

Hippocrates  treated  at  length,  in  one  of  his  works,  of  the  sani- 
tary influences  of  the  soil.  Others  of  the  older  writers,  especially 
Herodotus  and  Galen,  called  attention  to  the  same  subject,  and  Vitru- 
vius,  the  celebrated  Eoman  architect,  who  flourished  at  the  beginning 
of  the  Christian  era,  taught  that  a  point  of  first  importance  in  build- 
ing a  dwelling  was  to  select  a  site  upon  a  healthy  soil. 

From  this  time  until  the  beginning  of  the  eighteenth  century, 
very  little  of  value  is  found  in  medical  literature  bearing  upon  this 
subject.  In  1717,  however,  Lancisi  published  his  great  work  on  the 
causes  of  malarial  fevers,  in  which  he  laid  the  foundation  for  the 
miasmatic  theory  of  malaria,  and  pointed  out  the  relations  existing  be- 
tween marshes  and  low-lying  lands  and  those  diseases  by  common 
consent  called  malarial.  Other  authors  of  the  eighteenth  and  the 
early  part  of  the  nineteenth  centuries  refer  to  the  connection  be- 
tween the  soil  and  disease,  but  exact  investigations  have  only  been 
made  within  the  last  thirty  years. 

When  it  is  considered  that  the  air  that  human  beings  breathe, 
and  much  of  the  water  they  drink,  are  influenced  in  their  composi- 
tion by  the  matters  in  the  soil,  the  great  importance  of  possessing  a 
thorough  loiowledge  of  the  physical  and  chemical  conditions  of  the 
soil  becomes  evident  to  every  one. 

PHYSICAL   AND   CHEMICAL   CHARACTERS   OF  THE   SOIL. 

In  the  hygienic,  as  in  the  geological  sense,  rock,  sand,  clay,  and 
gravel  are  included  in  the  consideration  of  soils. 

The  soil,  as  it  is  presented  to  us  at  the  surface  of  the  earth,  is 
the  result  of  long  ages  of  disintegration  of  the  primitive  rocks  by  the 
action  of  the  elements,  of  the  decomposition  of  organic  remains,  and, 
possibly,  of  accretions  of  cosmical  dust.  The  principal  factor,  how- 
ever, is  the  action  of  water  upon  rock,  in  leveling  the  projections  of 
the  earth's  surface  produced  by  volcanic  action. 

Soils  vary  considerably  in  physical  and  chemical  constitution. 
A  soil  may,  for  example,  consist  exclusively  of  sand,  of  clay,  or  of 

(160) 


THE  ATMOSPHERE  OF  THE  SOIL,  OR  GROUND-AlR,  161 

disintegrated  calcareous  matter.  Other  soils  may  consist  of  a  mixture 
of  two  or  more  of  these,  together  with  vegetable  matter  undergoing 
slow  oxidation.  In  forests,  a  layer  of  this  slowly-decomposing  vege- 
table matter  of  varying  thickness  is  found,  covering  the  earthy  sub- 
stratum. This  organic  layer  is  called  humus,  and  when  turned  under 
by  plough  or  spade,  and  mixed  with  the  sand  or  clay  base,  it  con- 
stitutes the  ordinary  agricultural  soil. 


THE   ATMOSPHERE   OF  THE   SOIL,   OR  GROUND=AIR. 

The  interstices  of  the  soil  are  occupied  by  air  or  water,  or  by 
both  together.  The  soil's  atmosphere  is  continuous  with,  and  resem- 
bles in  physical  and  chemical  properties,  that  which  envelops  the 
earth.  Its  proportion  to  the  mass  of  the  soil  depends  upon  the  de- 
gree of  porosity  of  the  soil,  and  upon  the  amount  of  moisture  pres- 
ent. In  a  very  porous  soil,  such  as,  for  example,  a  coarse  sand, 
gravelly  loam,  or  coarse-grained  sandstone,  the  amount  of  air  is  much 
greater  than  in  a  claj^ey  soil,  granite,  or  marble.  So,  likewise,  when 
the  soil  contains  a  large  proportion  of  water,  the  air  is  to  this  extent 
excluded.  The  porosity  of  the  various  soils,  as  evidenced  by  the 
amount  of  air  contained  in  them,  is  much  greater  than  would,  at  first 
thought,  be  supposed.  Thus,  it  has  been  found  that  porous  sandstone 
may  contain  as  much  as  one-third  of  its  bulk  of  air,  while  the  pro- 
portion of  air  contained  in  sand,  gravel,  or  loose  soil  may  amount 
to  from  30  to  50  per  cent. 

The  ground-air  is  simply  the  atmospheric  air  which  has  pene- 
trated into  the  interstices  of  the  soil  and  taken  part  in  the  various 
chemical  decompositions  going  on  there.  In  consequence  of  these 
chemical  changes  the  relative  proportions  of  the  oxygen  and  car- 
bonic acid  in  the  air  are  changed — oxygen  disappearing  and  giving 
place  to  carbon  dioxide.  It  is  well  known  that  during  the  decay  of 
vegetable  matter  in  the  air  carbon  dioxide  is  formed;  one  constituent 
of  this  compound,  the  carbon,  being  derived  from  the  vegetable 
matter,  while  the  oxygen  is  taken  from  the  air.  Hence,  if  this  ac- 
tion takes  place  where  there  is  not  a  free  circulation  of  air,  as  in  the 
soil,  the  air  there  present  soon  loses  its  normal  proportion  of  oxygen, 
which  enters  into  combination  with  the  carbon  of  the  vegetable  matter 
to  form  carbon  dioxide. 

Over  thirty  years  ago,  MM.  Boussingault  and  Levy,  two  distin- 
guished French  chemists,  examined  the  air  contained  in  ordinary- 
agricultural  soil,  and  found  that  the  oxygen  was  diminished  to  about 

11 


162  TEXT-BOOK  OF  HYGIENE. 

one-half  of  the  projDortion  normally  present  in  atmospheric  air,  while 
the  carbon  dioxide  was  enormously  increased.  The  exact  results 
obtained  by  Boussingault  and  Levy  were  as  follows : — 

In  100  volumes  of  ground-air  there  were  10.35  volumes  of  oxy- 
gen, 79.91  volumes  of  nitrogen,  9.74  volumes  of  carbon  dioxide.  In 
atmospheric  air,  on  the  other  hand,  there  are  in  100  volumes  30.9  vol- 
umes of  oxygen,  79.1  volumes  of  nitrogen,  0.04  volume,  or  about 
^/2,5  of  1  per  cent,  of  carbon  dioxide. 

In  spite  of  the  striking  results  obtained  by  these  two  chemists, 
very  little  attention  was  paid  to  them  by  sanitarians,  as  very  few 
seemed  to  have  any  clear  notion  of  the  relations  existing  between  the 
motions  of  the  air  above  ground  and  that  under  ground. 

In  1871,  however.  Professor  von  Pettenkofer,  of  Munich,  pub- 
lished the  results  of  his  own  examinations  into  the  constitution  and 
physical  conditions  of  the  ground-air,  and  the  relations  of  the  latter 
to  the  propagation  of  epidemic  diseases.  These  researches,  which 
created  a  widespread  interest  in  the  sul^ject,  were  extended  by  other 
Qbservers  in  all  parts  of  the  world.  These  observers,  prominent  among 
whom  were  Professors  Fleck,  Fodor,  and  Soyka,  in  Germany;  Drs. 
Lewis  and  Cunningham,  in  India ;  Professor  William  Eipley  Nichols, 
in  Boston;  and  Surgeons  J.  H.  Kidder  and  S.  H.  Griffith,  of  the  U. 
S.  Navy,  in  Washington,  demonstrated  that  the  increase  of  carbon 
dioxide  in  the  ground-air  is  due  to  increased  vegetable  decomposition 
and  to  lessened  permeability  of  the  soil.  A  permeable,  that  is  to  say, 
a  sandy  or  gravelly  soil  is  likely  to  contain  less  carbon  dioxide  in  its 
atmosphere  than  a  dense,  less  permeable  clay,  although  the  amount 
of  decomposition  going  on  and  the  production  of  carbon  dioxide 
in  the  former  may  considerably  exceed  tbe  latter.  In  the  loose,  sandy 
soil  the  circulation  of  the  air  is  less  obstructed,  and  the  carbon  di- 
oxide may  easily  escape  and  be  diffused  in  the  superincumbent  air, 
while  the  close-pored  clay  imprisons  the  carbon  dioxide  and  pre- 
vents or  retards  its  escape  into  the  air  above. 

The  disappearance  of  oxygen  from  the  ground-atmosphere  is  coin- 
cident with  the  production  of  an  equivalent  amount  of  carbon  dioxide. 
It  appears  from  this  that  in  the  soil  an  oxidation  of  carbonaceous 
substances  takes  place,  the  product  of  which  is  found  in  the  excess 
of  carbon  dioxide  in  the  ground-air. 

Professor  Nichols  has  found  the  proportion  of  carbon  dioxide 
in  the  air  taken  from  a  depth  of  3  metres  below  the  surface  in  the 
"made-land"  of  Boston  to  amount  to  21.21  per  thousand,  the  obser- 
vation having  been  made  in  August.     In  December,  at  a  depth  of  2 


THE  ATMOSPHERE  OF  THE  SOIL,  OR  GROUND-AIR.  163 

metres,  the  proportion  was  3.23  per  thousand.  Fodor,  in  Buda- 
Pesth,  found  the  proportion  of  carbon  dioxide  to  be  107.5  per  thou- 
sand (over  10  per  cent.),  the  air  having  been  taken  from  a  depth  of 
3  metres. 

The  ground-air  also  teems  with  micro-organisms  of  various  kinds, 
these  being  occasionally  pathogenic.  While  in  the  great  majority  of 
instances  the  micro-organisms  found  are  ordinary  mold  or  fermen- 
tation fungi  and  bacteria  of  decay  and  putrefaction,  disease-produc- 
ing bacilli  have  also  been  observed  in  a  number  of  instances.  Among 
the  latter  are  the  bacillus  of  tetanus  (Nicolaier),  of  anthrax  (Frank), 
of  malignant  edema  (Koch  and  Gaffky),  and  of  typhoid  fever  (Tryde) . 

It  may  not  be  inappropriate  to  refer  here  to  the  claim  of  Pro- 
fessor Domingos  Freire,  of  Brazil,  to  the  discovery  of  the  germ  of 
yellow  fever  in  the  soil  of  a  burial  ground  near  Eio  Janeiro.  The 
exhaustive  investigations  of  Surgeon-General  G.  M.  Sternberg,  of  the 
U.  S.  Army,  under  the  direction  of  the  government,  have  disposed 
effectually  of  the  claims  and  pretensions  of  the  Brazilian  scientist, 
and  established  the  fact  that  Freire's  organism  has  no  pathological 
significance  whatever— at  all  events,  that  it  has  no  relation  to  yellow 
fever. 

Cholera  bacilli  have  not  been  found  in  the  soil,  but  C.  Frankel 
has  shown  experimentally  that  they  can  grow  and  multiply  in  the  soil 
at  various  depths.  At  a  depth  of  1^/,  metres  their  development  was 
constant  and  progressive  throughout  the  year.  With  regard  to  ty- 
phoid bacilli,  Houston  found  that  under  ordinary  condition  they  die 
out  in  the  course  of  a  few  days  to  a  few  weeks. 

When  the  soil  is  dry,  these  organisms  may  be  carried  hither  and 
thither  in  the  movements  of  the  ground-air,  and  thus  be  transported 
to  a   distance. 

Movements  of  the  ground-atmosphere  are  principally  due  to  dif- 
ferences of  pressure  and  temperature  in  the  air  above  ground.  Owing 
to  such  differences  the  air  from  the  soil  frequently  permeates  houses, 
entering  from  cellars  or  basements.  In  winter,  when  the  air  of  houses 
is  very  much  more  heated  (and  consequently  less  dense)  than  the  air 
out-of-doors,  the  difference  of  pressure  thus  caused  draws  the  ground- 
air  up  through  the  house,  while  the  cold,  external  atmosphere  pene- 
trates the  soil  and  occupies  the  place  of  the  displaced  ground-air.^ 
A  similar  effect  occurs  in  consequence  of  heavy  rains.    The  water  fills 

'  Tt  is,  of  course,  not  strictly  correct  to  say  thnt  tTie  air  is  drnivn  tip 
throuf^h  the  house  by  the  diminution  of  pressure;  it  being  rather  forced  out 
of  the  soil  bv  the  colder  and  denser  outside  air;  but  the  phrase  is  sufficiently 
exact  and  will  be  readily  understood. 


164  TEXT-BOOK  OF  HYGIENE. 

up  the  interstices  of  the  soil  near  the  surface,  and  forces  the  ground- 
air  out  at  points  where  the  pores  remain  open.  These  places  are  the 
dry  ground  under  buildings,  where  the  air  escapes  and  passes  through 
floors  and  ceilings  into  the  house  above.  Heavy  rains  may  thus  be 
the  cause  of  pollution  of  the  air  in  houses.  The  greater  the  porosity 
of  the  soil,  the  more  likely  is  this  to  happen.  This  pollution  of  the 
house-air  may  be  prevented  by  having  impervious  floors  and  walls 
to  cellars  and  basements,  or  by  interposing  a  layer  of  charcoal  between 
the  ground  and  the  floor  of  the  house.  The  latter  does  not  prevent 
the  passage  of  the  ground-air,  but  the  charcoal  layer  absorbs  or  arrests 
the  noxious  matters — filters  the  ground-air,  as  it  were. 

In  the  spring  and  early  summer  the  ground  being  colder  than 
the  air  above  it,  and  the  ground-air  consequently  heavier  and  denser, 
the  latter  is  not  easily  displaced.  It  is,  perhaps,  due  to  this  fact  that 
those  infectious  diseases  which  are  probably  dej)endent  upon  the 
movements  of  the  ground-air  are  less  prevalent  in  the  spring  and 
early  summer  than  in  the  latter  part  of  the  summer,  autumn,  and 
early  winter.  In  the  autumn  the  ground-air  being  warmer  than  the 
air  above  ground  is  easily  displaced  by  the  latter  and  forced  out  into 
the  streets  and  houses  to  be  inspired  by  men  and  animals.  The 
colder  outside  air  penetrates  the  interstices  of  the  soil  and  forces 
out  the  impure  ground-air. 

The  researches  of  Fodor  have  demonstrated  that  the  propor- 
tion of  carbon  dioxide  in  the  ground-air  may  be  taken  as  an  approxi- 
mate measure  of  the  impurity  of  the  soil  whence  the  air  is  taken. 
The  influence  of  the  permeability  of  the  soil,  as  before  pointed  out, 
must,  however,  not  be  overlooked  in  estimating  the  signification  of 
the  carbon  dioxide.  Fodor  has  sho^\Ti  that  the  proportion  of  carbon 
dioxide  in  the  ground-air,  and  consequently  the  amount  of  organic 
decomposition,  is  greatest  in  July  and  least  in  ]\Iarch.  That  the  car- 
bon dioxide  is  derived  from  the  decomposition  of  vegetable  matter 
has  been  proven  by  Pettenkofer.  This  observer  examined  specimens 
of  air  brought  from  the  Lybian  desert,  and  found  that  the  propor- 
tion of  carbon  dioxide  in  the  ground-air  Avas  exactly  the  same  as  in 
the  air  collected  above  ground.  There  being  no  vegetable  growth 
in  the  desert  there  can,  of  course,  be  no  vegetable  decomposition  going 
on  in  the  soil. 

The  excess  of  carbon  dioxide  in  the  ground-air  is  an  indication 
of  the  deficiency  of  oxygen,  as  has  been  sho^^Ti.  The  air  at  a  depth  of 
4  metres  below  the  surface  was  found  to  contain  only  from  7  to  10 
per  cent,  of  oxygen — one-half  to  one-third  of  the  normal  proportion. 


THE  WATER  OF  THE  SOIL,  OR  GROUND-WATER.  165 

Many  basements  occupied  by  people  as  living-rooms  extend  from  1  to 
3  metres  underground,  and  hence  are  liable  to  be  supplied  with  an 
atmosphere  approaching  in  impurity  that  just  mentioned.  It  requires 
no  very  vivid  imagination  to  appreciate  the  dangers  to  health  that 
lurk  in  such  habitations. 


THE  WATER  OF  THE  SOIL,  OR  GROUND=WATER. 

At  a  variable  depth  below  the  surface  of  the  ground,  a  stratum 
of  earth  or  rock  is  found  through  which  water  passes  with  difficulty, 
if  at  all.  Above  this  there  is  a  stratum  of  water  which  moves  from 
a  higher  to  a  lower  level,  and  which  varies  in  depth  at  difEerent  times 
according  to  the  amount  of  precipitation  (rain-  or  snow-  fall),  and 
according  to  the  level  of  the  nearest  body  of  water  toward  which  it 
flows.  This  stratum  of  water  is  termed  ground-water,  and  has  within 
the  last  few  years  assumed  considerable  importance  from  its  appar- 
ently close  relation  to  the  spread  of  certain  of  the  infectious  diseases. 
The  direction  of  horizontal  flow  of  ground- water  is  always  toward 
the  drainage-area  of  the  district.  Thus,  it  is  usually  toward  lakes, 
rivers,  or  the  sea.  Eains,  or  a  rise  in  the  river,  cause  a  rise  in  the 
ground-water,  while  long-continued  dry  weather,  or  a  low  stage  of  the 
river  which  drains  off  the  ground-water,  causes  a  fall  in  the  latter. 
On  the  sea-coast  the  ground-water  oscillations  probably  correspond 
with  the  tides.  The  writer  is  not  aware  of  any  observations  made 
to  determine  this  point,  with  the  exception  of  a  single  instance  men- 
tioned by  Dr.  De  Chaumont.  In  Munich,  where  the  ground-water 
flows  toward  the  river  Isar,  which  divides  the  city,  it  has  been  found 
that  the  annual  range  or  oscillation  (the  difference  between  the  high- 
est and  lowest  level  during  the  year)  is  about  3  metres,  while  the 
horizontal  movement  amounts  to  5  metres  per  day.  In  Buda-Pesth 
the  annual  range  was  found  by  Fodor  to  be  less  than  1  metre,  while  in 
some  portions  of  India  it  amounts  to  more  than  12  metres.  As  it  is 
from  the  ground-water  that  the  greater  portion  of  the  supply  of 
drinking-water  in  the  country  and  in  villages  and  small  towns  is 
drawn,  it  becomes  at  once  manifest  how  important  it  is  to  prevent,  as 
far  as  possible,  pollution  of  this  source.  Cess-pools  and  manure-heaps 
and  pits,  of  necessity,  contaminate  the  soil  and  also  the  ground- 
water for  a  distance  below  and  around  them,  and  such  water  is 
clearly  unfit  for  drinking  and  other  domestic  purposes.  Hence,  the 
reason  why  wells  should  not  be  placed  too  near  privies  and  manure- 
heaps  or  pits  becomes  apparent. 


166  TEXT-BOOK  OF  HYGIENE. 

Between  the  level  of  tlie  ground-water,  or  that  portion  of  the 
soil  where  its  pores  are  entirely  occupied  by  water — where,  in  other 
words,  the  ground  is  saturated — and  the  surface,  is  a  stratum  of  earth 
more  or  less  moist;  that  is  to  say,  the  interstices  of  the  soil  are  partly 
filled  with  water  and  partly  with  air.  It  is  in  this  stratum  that  the 
processes  of  organic  decay  or  putrefaction  are  most  rapidly  going  on, 
in  consequence  of  which  the  pollution  of  the  ground-air  occurs.  The 
oxidation  of  non-nitrogenous  matter  in  the  soil  results  in  the  forma- 
tion of  carbon  dioxide.  On  the  other  hand,  nitrogenized  compounds 
are  oxidized  into  nitric  acid  and  nitrates.  When,  however,  putrefac- 
tion occurs,  nitrous  acid,  or  nitrites  and  ammonia,  are  formed,  the 
oxidation  not  proceeding  far  enough  to  result  in  nitric  acid. 

Eecent  observations  seem  to  show  that  these  processes  of  decom- 
position are  initiated  and  kept  up  by  hacteria,  just  as  fermentation 
in  liquids  containing  sugar  can  only  take  place  in  the  presence  of  the 
yeast-plant.  It  has  been  found  that  when  non-putrefactive  decompo- 
sition goes  on,  there  are  always  present  multitudes  of  one  variety  of 
these  minute  organisms;  while  if  putrefactive  decomposition  is  going 
on,  a  number  of  other  varieties  of  these  organisms  are  present.  Just 
as,  when  a  fermenting  liquid  becomes  putrid,  the  yeast-plant  disap- 
pears and  its  place  is  taken  by  the  ordinary  bacteria  of  putrefac- 
tion, so  in  the  soil,  if  the  access  of  oxygen,  which  is  necessary  to  the 
life  of  the  bacteria  of  decay,  is  prevented,  these  organisms  die  and 
are  succeeded  by  the  organisms  of  putrefaction.  It  has  been  found 
that  in  a  soil  saturated  with  water  the  bacteria  of  decay  cannot  live, 
while  those  of  putrefaction  may  flourish,  because  these  latter  organ- 
isms can  sustain  life  and  develop  in  the  absence  of  oxygen.  Professor 
Fodor's  researches  indicate  that  the  most  prominent  organism  of  non- 
putrefactive  decomposition  or  decay  is  that  which  is  termed  by  Cohn 
hacterium  Hneola;  and  that  the  hacterium  termo  is  the  principal 
organism  of  putrefaction. 

DISEASES  SPREAD   BY  SOIL  IMPURITIES. 

Given  now  an  area  of  soil,  say  the  ground  upon  which  a  house 
or  city  is  built,  with  a  moist  stratum  in  which  the  processes  of  decay 
are  active,  and  imagine  a  rise  in  the  ground-water.  The  ground-air, 
charged  with  carbon  dioxide  and  other  products  of  decomposition,  is 
forced  out  of  the  pores  of  the  soil  by  the  rising  ground-water,  and 
escapes  into  the  external  air,  or  through  cellars  and  basements  into 
houses,  and  may  there  produce  disease.     But  the  saturation  of  the 


DISEASES  SPREAD  BY  SOIL  IMPURITIES.  167 

soil  with  water  prevents  the  further  development  of  the  bacteria  of 
decay,  and  this  is  checked,  or  putrefaction  may  take  place.  If  now 
the  ground-water  sinks  to  its  former  level  or  below,  the  processes  of 
decay  again  become  very  active  in  the  moist  stratum,  and  large 
quantities  of  carbon  dioxide  and  other  inorganic  compounds  are 
produced.  If  the  germs  of  infectious  or  contagious  diseases  have  been 
introduced  into  the  soil,  they  also  multiply  and,  by  gaining  access  to 
the  well  or  stream  from  which  the  drinking-water  is  obtained,  they 
may  cause  infection.  Professor  De  Chaumont  has  laid  down  the  rule 
that  a  soil  with  a  persistently  low  stage  of  ground-water,  say  5  metres 
below  the  surface  of  the  ground,  is  healthy;  a  persistently  high  stage 
of  ground-water,  less  than  1 V2  metres  below  the  surface,  is  unhealthy ; 
while  a  fluctuating  level  of  the  ground-water,  especially  if  the  changes 
are  sudden  and  violent,  is  very  unhealthy.  This  would  lead  us  to 
expect  that  places  where  this  fluctuation  is  very  great  would  show 
a  large  mortality  from  such  diseases  as  are  attributed  to  impurities  in 
the  soil.  And  this  we  find  especially  true  in  India.  In  certain  local- 
ities in  India,  cholera,  for  example,  is  endemic;  that  is  to  say,  the 
disease  is  never  entirely  absent  in  such  localities.  Calcutta  is  one  of 
these  places.  The  rainy  season  begins  about  the  first  of  May  and  con- 
tinues until  the  end  of  October.  During  the  next  six  months  there 
is  very  little  rain.  It  is  fair  to  assume  that  the  ground-water  rises 
during  the  rainy  season  and  checks  decay  and  the  multiplication  of 
the  germs  of  the  disease  in  the  soil,  and  that  these  processes  become 
more  active  as  the  dry  season  advances  and  the  ground-water  level 
falls.  If  we  note  the  death-rate  from  cholera  in  Calcutta  it  will  be 
found  that  it  bears  a  distinct  relation  to  the  movement  of  the  ground- 
water. The  deaths  from  cholera  begin  to  increase  from  October  and 
reach  their  height  in  April.  Dr.  Macpherson,  who  has  written  a  very 
elaborate  history  of  Asiatic  cholera,  shows  this  relation  very  clearly. 
For  twenty-six  years  the  average  rain-fall  was  157  centimetres.  From 
May  to  October  142  centimetres  fell,  while  the  remaining  15  centi- 
metres fell  from  November  to  April.  The  average  number  of  deaths 
from  cholera  annually  was  4013.  Of  these,  1238  died  in  the  rainy 
season,  while  2775,  nearly  three-fourths,  died  during  the  period  of 
dry  weather. 

In  the  cholera  epidemics  of  1866  and  1873  in  Buda-Pesth,  the 
same  relations  existed  between  the  ground-water  and  the  cholera.  As 
the  level  of  the  ground-water  rose  the  cholera  diminished,  while  the 
disease  increased  upon  tlie  sinking  of  the  ground-water.  Exactly  the 
same  behavior  was  exhibited  by  the  disease  in  Munich  in  1873. 


168  TEXT-BOOK  OF  HYGIENE. 

There  seems  good  reason  to  believe  that  typhoid  fever  bears  some 
relation  to  the  movements  of  the  ground-water  in  the  same  way  as 
above  explained  for  cholera.  Pettenkofer,  Buhl,  and  Virchow  have 
shown  that  the  death-rate  from  typhoid  fever  has  a  distinct  and 
definite  relation  to  the  ground-water  oscillations.  This  has  been  in- 
contestably  proven  for  two  cities,  Munich  and  Berlin.  When  the 
level  of  the  ground-water  is  above  the  average,  typhoid  fever  de- 
creases; when  it  is  below  the  average,  the  number  of  cases  becomes 
greater.  Dr.  H.  B.  Baker  has  demonstrated  that  the  fluctuation 
of  the  ground-water  level  in  the  State  of  Michigan  is  similarly  fol- 
lowed by  a  change  in  the  morbidity  and  mortality  from  typhoid  fever.^ 

Over  thirty  years  ago  Dr.  Henry  I.  Bowditch,  of  Boston,  called 
attention  to  the  frequent  connection  between  cases  of  pulmonary  con- 
sumption and  dampness  of  the  soil  upon  which  the  patients  lived. 
After  a  very  extended  and  laborious  investigation  Dr.  Bowditch  for- 
mulated these  two  propositions : — 

''First. — A  residence  in  or  near  a  damp  soil,  whether  that  damp- 
ness be  inherent  in  the  soil  itself  or  caused  by  percolation  from  ad- 
jacent ponds,  rivers,  meadows,  or  springy  soils,  is  one  of  the  prin- 
cipal causes  of  consumption  in  Massachusetts,  probably  in  New  Eng- 
land, and  possibly  other  portions  of  the  globe. 

"Second. — Consumption  can  be  checked  in  its  career,  and  possi- 
bly— ^nay,  probably — prevented  in  some  instances  by  attention  to  this 
law."3 

Dr.  Buchanan,  of  England,  about  the  same  time  showed  that 
the  thorough  drainage  of  certain  English  cities  had  markedly  dimin- 
ished the  deaths  from  consumption  in  the  drained  cities.  So  far  as 
the  writer  is  aware,  not  a  single  fact  has  been  established  which 
militates  against  the  law  laid  down  by  Dr.  Bowditch,  and  so  strongly 
supported  by  the  statistical  researches  of  Dr.  Buchanan,  yet  hardly 
any  notice  has  been  taken  of  these  results  by  physicians.  Eew  know 
anything  of  them,  and  still  fewer  seem  to  have  made  practical  use 
of  such  knowledge  in  advising  patients.  As  corroborative  of  the  views 
of  Dr.  Bowditch,  the  rarity  of  consumption  in  high  and  dry  moun- 
tainous districts  or  plateaus  may  be  cited. 

A  study  of  the  topographical  distribution  of  consumption  in  the 
State  of  Pennsylvania,  by  Dr.  William  Pepper,  apparently  confirms 
Dr.  Bowditch's   conclusions  in  nearly   every  particular.      It   is  now 

-The  Relation  of  the  Depth  of  Water  in  Wells  to  the  Causation  of 
Typhoid  Fever,  Public  Health,  vol.  x,  p.  184-213. 

^  Consumption  in  New  England  and  Elsewhere,  2d  ed.,  p.  87.  Boston, 
1866. 


DISEASES  OF  ANIMALS  DUE  TO  CONDITIONS  OF  SOIL.        169 

known  that  the  direct  cause  of  consumption  is  the  bacilhis  tuberculosis, 
discovered  by  Dr.  Robert  Koch.  The  relation  between  soil-moisture 
and  the  increase  of  consumption  will  probably  be  found  in  the  more 
favorable  conditions  of  development  of  the  tubercle  bacillus  fur- 
nished by  a  moist  medium. 


DISEASES    OF    ANIMALS    PROBABLY    DUE    TO    SIMILAR 
CONDITIONS  OF  THE  SOIL. 

The  modern  study  of  the  sanitary  relations  of  the  soil  is  still  in 
its  infancy.  Whatever  definite  knowledge  has  been  gained  relates 
merely  to  physical  or  chemical  conditions  of  the  soil  and  its  atmos- 
phere and  moisture,  or  possibly  the  relations  of  these  to  the  spread 
of  certain  diseases  in  human  beings.  But  there  is,  perhaps,  a  wider 
application  that  may  be  made  of  such  knowledge  than  has  been  here- 
tofore suggested.  The  domestic  animals  which  form  such  a  large  por- 
tion of  the  wealth  of  this  country — horses,  cattle,  sheep,  and  hogs — 
are  liable  to  infectious  and  contagious  diseases,  as  well  as  are  human 
beings,  and  many  millions  of  dollars  are  lost  annually  by  the  ravages 
of  such  diseases.  Now,  from  what  is  known  of  such  diseases  as 
sple^iic  fever  among  cattle,  and  of  the  so-cal'ed  sivine-plague,  it  does 
not  appear  improbable  to  the  writer  that  the  source  of  infection  is  a 
soil  polluted  by  the  poisonous  germ  of  these  diseases.  The  laborious 
investigations  of  M.  Pasteur  in  France  have  shown  that  the  cause  of 
splenic  fever,  when  once  introduced  into  a  locality,  will  remain  active 
for  months,  and  even  years,  and  it  seems  probable  that  a  study  of  the 
soil  in  its  relation  to  the  diseases  of  domestic  animals  is  a  subject  to 
which  attention  may  profitably  be  given. 

It  is  well  known  that  milch-cows  frequently  suffer  from  a  disease 
identical  in  its  nature  with  consumption  in  human  beings.  It  is  be- 
lieved by  many  that  the  milk  of  such  animals  is  not  only  unfit  for 
food  by  reason  of  its  poor  quality,  but  that  it  may  convey  the  dis- 
ease to  human  beings  when  used  as  food.  The  observations  of  Bow- 
ditch  and  Buchanan,  quoted  above,  show  that  consumption  in  man 
may  be,  and  doubtless  is,  frequently  favored  by  soil-wetness.  It  seems 
probable  that  the  same  cause  should  produce  similar  effects  in  the 
lower  animals,  and  it  is  the  writer's  firm  conviction  that  an  exam- 
ination into  the  circumstances  under  which  cows  become  attacked  by 
consumption  would  prove  this  probability  a  fact. 


170  TEXT-BOOK  OF  HYGIENE. 

DRAINAGE 

In  many  soils  drainage  is  necessary  in  order  to  secure  a  constant 
level  of  the  ground-water  at  a  sufficient  depth  below  the  surface. 
Drainage  and  sewerage  must  not  be  confounded  with  each  other. 
Drainage  contemplates  only  the  removal  of  the  ground-water,  or  the 
reduction  of  its  level,  while  sewerage  aims  to  remove  the  refuse  from 
dwellings  and  manufactories,  including  excrementitious  matters, 
waste-water,  and  other  products,  and  in  some  cases  the  storm-water. 

Sewers  should  never  be  used  as  drains,  although  for  economy's 
sake  sewer-  and  drainage-  pipes  may  be  laid  in  the  same  trench. 
Sewer-pipe  must  be  perfectly  air-tight  and  water-tight  to  prevent 
escape  of  its  liquid  or  gaseous  contents  into  the  surrounding  soil  and 
rendering  it  impure.  Drainage-pipe,  on  the  other  hand,  should  be 
porous  and  admit  water  freely  from  without.  Escape  of  the  contents 
of  the  drain-pipe  into  the  surrounding  soil  will  not  produce  any  pol- 
lution of  the  latter. 

The  best  material  for  drains  is  porous  earthenware  pipe,  or  the 
ordinary  agricultural  drain-tile.  Coarse  gravel  or  broken  stones  may 
also  be  used,  and  prove  efficient  if  the  drains  are  properly  constructed. 
Eeferring  again  to  the  aphorism  of  Professor  De  Chaumont,  that  a 
persistently  low  ground-water,  say  5  metres  down,  or  more,  is  healthy ; 
that  a  persistently  high  ground-water,  less  than  l^/o  metres  from  the 
surface,  is  imhealthy,  and  that  a  fluctuating  level,  especially  if  the 
changes  are  sudden  and  violent,  is  very  unhealthy,  the  necessity  ap- 
pears obvious,  that  in  the  construction  of  drainage- works  the  drains 
should  be  placed  at  a  sufficient  depth  to  secure  a  level  of  the  ground- 
water consistent  with  health.  This  depth  should  never  be  less  than 
3  metres,  and,  if  possible,  not  less  than  5  metres.  Care  must  be  taken 
that  the  outflow  of  the  drain  is  unobstructed,  in  order  that  the  soil 
may  be  kept  properly  dry  at  all  times. 

In  the  absence  of  a  proper  mechanical  system  of  drainage,  the 
planting  of  certain  trees  may  efficiently  drain  the  soil.  It  has  been 
found  that  the  eucalyptus  tree  has  produced  drying  of  the  soil  when 
planted  in  sufficient  numbers  in  marshy  land.  The  roots  absorb 
a  prodigious  quantity  of  water,  which  is  then  given  off  by  evapora- 
tion from  the  leaves.  Sunflower-plants  have  a  similar  effect  upon 
wet  soils.  It  is  for  this  reason  that  the  planting  of  eucalyptus  trees 
is  recommended  in  malarial  regions. 


QUESTIONS  TO  CHAPTER  IV. 

THE  SOIL. 

Why  is  it  necessary  to  possess  a  knowledge  of  the  physical  and  chemical 
conditions  of  the  soil?  What  substances  are  included  in  the  consideration  of 
soils?  Of  what  is  the  surface  soil  composed?  How  do  soils  vary  in  composi- 
tion, physically  and  chemically? 

What  occupies  the  interstices  of  the  soil?  Upon  what  does  the  propor- 
tion of  air  in  the  soil  depend?  Is  this  proportion  comparatively  great  or 
small?  What  relation  has  the  soil-air  to  the  atmosphere  air,  and  what  causes 
the  difference  in  composition?  In  what  way  does  the  soil-air  differ  from  the 
atmospheric  air?  Has  the  soil-air  any  definite  composition?  What  are  the 
factors  governing  the  variation  in  composition?  What  kind  of  a  soil  will  be 
likely  to  contain  most  carbon  dioxide  and  least  oxygen?  What  does  this  indi- 
cate? What  micro-organisms  are  always  to  be  found  in  the  soil-air?  What 
pathogenic  organisms  may  also  make  the  soil  and  soil-air  their  habitat?  How 
may  these  be  carried  from  place  to  place?  To  what  are  movements  of  the 
ground-air  due?  How  may  this  soil-air  gain  access  to  our  houses,  and  what 
measures  should  be  taken  to  prevent  its  entrance?  When  is  the  danger 
greatest?  Why  are  certain  infectious  diseases  less  prevalent  in  spring  and 
early  summer  than  in  autumn?  Why  is  there  greater  danger  of  infection  from 
these  diseases  at  night  than  in  the  day-time?  Is  the  carbon  dioxide  of  the 
soil-air  a  measure  of  the  impurity  of  the  soil?  What  causes  the  excess  of 
carbon  dioxide?  When  is  the  proportion  of  carbon  dioxide  greatest?  Why 
are  living-apartments  below  the  surface  of  the  ground  very  apt  to  be  un- 
healthy? 

What  is  meant  by  the  term  "ground-water"?  Where  is  it  to  be  found? 
Has  it  a  definite  current?  In  what  direction  is  the  flow?  Upon  what  does 
the  level  of  the  ground-water  depend?  What  class  of  the  population  derive 
their  drinking-water  largely  from  the  ground-water?  ^^Tiat  are  som.e  of  the 
sources  of  contamination  of  the  ground-water?  What  are  some  of  the  deduc- 
tions to  be  made  accordingly? 

In  what  part  of  the  soil  do  the  processes  of  organic  decay  and  putrefac- 
tion occur  most  readily?  What  are  the  causes  of  these  processes?  What  are 
some  of  their  products?  What  is  the  distinction  between  non-putrefactive 
decomposition  or  decay  and  putrefaction? 

How  may  disease  be  spread  by  the  rise  and  fall  of  the  ground- water  ? 
WTiat  two  infective  diseases  are  especially  apt  to  be  transmitted  in  this  way? 
Give  instances  that  tend  to  prove  this.  Upon  what  other  disease  has  a  damp 
soil  a  directly  causative  influence?  What  diseases  of  animals  are  likely  to  be 
influenced  in  a  similar  manner?  How  deep  below  the  surface  should  the  soil- 
water  persistently  be  that  the  soil  may  be  healthy?  Wliat  effect  upon  health 
has  a  suddenly  and  markedly  fluctuating  soil-water?  Is  a  soil  with  its  water 
persistently  near  the  surface  apt  to  be  healthy? 

What  do  we  mean  by  drainage,  and  what  are  its  object  and  function? 
What  is  the  difference  between  it  and  sewerage?  How  should  drains  be  laid? 
What  is  the  best  material  for  drains?  What  precautions  must  be  observed  in 
the  laying  of  drains?  How  may  the  surplus  water  be  taken  from  the  soil 
otherwise  than  by  drains? 

(171) 


CHAPTER  V. 

REMOVAL  OF  SEWAGE. 

In  all  larger  communities  certain  arrangements  are  necessary  to 
secure  a  prompt  and  efficient  removal  of  excreta  and  the  refuse  and 
used  water  of  households  and  manufacturing  establishments,  the 
sweepings  of  streets,  and  rain-water. 

The  total  quantity  of  excrementitious  products — feces  and  urine 
— for  each  individual,  including  men,  women,  and  children,  has  been 
estimated  by  Professor  von  Pettenkofer  as  90  grammes  of  fecal  and 
1170  grammes  of  urinary  discharge  daily.  This  would  give  for  a 
population  of  1000  persons  34,000  kilogrammes  of  feces  and  428,000 
litres  of  urine  per  year.  If  to  this  is  added  a  minimum  allowance 
of  159  litres  of  water  per  day  to  each  individual,  a  complete  sewerage 
system  for  a  population  of  1000  persons  would  require  provision  for 
the  discharge  of  160,000  litres  of  sewage  passing  through  the  sewers 
every  day.  In  this  estimate  storm-water  and  such  accessory  feeders 
of  the  sewers  are  omitted. 

The  organic  matters  contained  in  sewage,  even  if  free  from  the 
specific  germs  of  disease,  give  rise  to  noxious  emanations,  which,  when 
inhaled,  probably  produce  a  gradual  depravement  of  nutrition  that 
renders  the  system  an  easier  prey  to  disease.  For  this  and  other 
reasons  it  is  imjDortant  that  such  measures  be  adopted  as  will  secure 
the  removal  of  sewage  matters  from  the  immediate  vicinity  of  houses 
as  quickly  as  possible  after  they  have  been  discharged. 

The  impregnation  of  the  soil  with  sewage  produces  a  contamina- 
tion of  ground-air  and  ground-water,  which  may  become  a  source  of 
grave  danger  to  health.  By  polluting  the  ground-water  it  eventually 
vitiates  the  well-water,  which  is  nearly  always  derived  from  that 
source. 

The  system  of  removal  of  excrementitious  matters  which  any 
community  will  adopt  depends  to  a  considerable  extent  upon  financial 
considerations.  Although  the  sanitarian  must  insist  upon  the  pre-emi- 
nent importance  of  the  cause  of  public  health,  his  suggestions  will  re- 
ceive little  attention  from  municipal  or  State  legislatures  unless  they 
can  be  carried  out  without  involving  the  community  too  deeply  in  debt. 
For  this  reason  it  is  a  matter  of  great  practical  importance  that  the 
(173) 


REMOVAL  OF  SEWAGE.  173 

student  of  sanitary  science  should  make  liimself  familiar  with  the 
relative  cost  as  well  as  with  the  hygienic  significance  of  the  various 
methods  of  sewage  removal  in  use. 

The  different  systems  in  use  for  the  removal  of  sewage  matters 
may  be  considered  in  detail  under  the  following  five  heads: — 

1.  The  common  privy,  or  privy-vault  system. 

2.  The  Eochdale  or  pail  system,  and  its  modifications. 

3.  The  earth-  or  ash-  closet  system. 

4.  The  pneumatic  system  of  Liernur. 

5.  The  water-carriage  systems. 

1.  The  Privy  and  Privy-well  Systems. — While  from  a  sanitary 
point  of  view  privies  of  all  kinds,  whether  wells  or  cess-pits,  are  to 
be  unreservedly  condemned,  it  is  not  likely  that  they  will  cease  to 
be  built  for  many  years  to  come.  It  becomes  necessary,  therefore,  to 
point  out  by  what  means  the  objections  against  them  may  be  dimin- 
ished, and  their  evil  consequences  in  some  measure  averted. 

In  the  first  place,  a  privy-vault  should  be  perfectly  water-tight, 
in  order  to  prevent  pollution  of  the  surrounding  soil  by  transudation 
of  the  contained  excremental  matters.  The  walls  should  be  of  hard- 
burned  brick  laid  in  cement.  The  cavity  should  be  small  in  order  that 
the  contents  may  be  frequently  removed,  and  not  allowed  to  remain 
and  putrefy  for  months  or  years.  A  water-tight  hogshead  sunk  in  the 
ground  makes  an  economical  privy-tank  or  receiver.  A  privy  must 
not  be  dug  in  a  cellar,  or  in  too  close  proximity  to  the  house-walls. 
Unless  these  last  precautions  are  taken  the  offensive  gases  from  the 
mass  of  decomposing  fecal  matter  in  the  privy  will  constantly  ascend 
into  and  permeate  the  air  of  the  house. 

All  privies  should  be  ventilated  by  a  pipe  passing  from  just  under 
the  privy-seat  to  a  height  of  about  a  metre  above  the  roof  of  the 
house.  A  gas-flame,  kept  burning  in  the  upper  portion  of  this  pipe, 
will  increase  its  ventilating  power  by  creating  a  strong  and  constant 
upward  current. 

Deodorization  of  the  contents  of  privies  may  be  secured  in  a 
measure  by  means  of  sulphate  of  iron,  phenyle,  carbolic  acid,  chloride 
of  lime,  or  dry  earth.  The  first  named  is  probably  the  most  econom- 
ical, most  easily  applied,  and  very  effective.  A  solution  containing 
from  ^/2  to  1  kilogramme  of  the  salt  in  4  litres  of  water  is  poured 
into  the  privy  as  often  as  necessary  to  prevent  offensive  odors.  This 
solution  may  be  conveniently  prepared  by  suspending  a  basket  or 
bag  containing  about  25  kilogrammes  of  the  sulphate  in  a  barrel  of 


174  TEXT-BOOK  OF  HYGIENE. 

water.  In  this  way  a  saturated  solution  will  be  maintained  until  the 
salt  has  been  entirely  dissolved.  Phenyle  is  likewise  a  good  deodor- 
izer as  well  as  an  excellent  disinfectant. 

The  most  rigid  deodorization  by  chemicals  will,  however,  be  less 
effective  than  thorough  ventilation,  for  it  must  be  remembered  that 
the  mere  destruction  of  an  offensive  odor  is  not  equivalent  to  remov- 
ing all  the  deleterious  properties  that  may  be  present.  It  is  not  at 
all  certain  that  those  elements  of  sewage  which  are  the  most  offensive 
to  the  sense  of  smell  are  most  detrimental  to  health. 

Privies  should  be  emptied  of  their  contents  at  stated  intervals. 
A  strict  supervision  should  be  exercised  over  them  by  the  municipal 
authorities  in  cities  and  towns  to  prevent  overflowing  of  their  con- 
tents. 

In  many  places  the  method  of  removing  the  contents  of  privies 
is  the  primitive  one  with  shovel,  or  dipper  and  bucket.  In  most 
cities  and  large  towns,  however,  the  privy-vaults  or  tanks  are  now 
emptied  by  means  of  one  of  the  so-called  odorless  excavating  machines, 
of  which  there  are  a  number  of  patents.  The  process  is  rarely 
entirely  odorless,  however,  as  the  carelessness  of  the  workmen  fre- 
quently permits  offensive  gases  to  escape  and  pollute  the  air  for  a 
considerable  distance.  All  the  different  forms  of  the  apparatus  act 
upon  the  pneumatic  principle.  One  end  of  a  large  tube  is  carried 
into  the  cess-pool  or  vault  to  be  emptied  and  the  other  attached  to 
a  pump,  by  means  of  which  the  material  is  pumped  into  a  strong  bar- 
rel-tank carried  on  wheels.  At  the  top  of  the  tank  is  a  vent,  over 
which  is  placed  a  small  charcoal  furnace  to  consume  the  foul  gases 
escaping  from  the  vent. 

In  some  cities  and  many  of  the  smaller  towns  and  villages  in 
this  country  the  primitive  midden  or  pit  system  is  still  in  use.  A 
shallow  pit  is  dug  in  the  ground,  over  which  is  erected  the  privy. 
When  the  pit  is  full  another  is  dug  close  by  the  side  of  it,  and  the 
earth  from  the  new  pit  thrown  upon  the  excrement  in  the  old  one. 
The  privy  is  then  moved  over  the  new  pit,  and  this  is  used  until  it 
too  becomes  full.  The  proceeding  is  repeated  as  often  as  the  pit  be- 
comes filled  up  with  the  excreta,  until  in  the  course  of  a  few  years  all 
the  available  space  in  a  yard  has  been  honey-combed  with  the  pits. 
Then  the  custom  adopted  in  overcrowded  cemeteries  is  followed, 
namely,  the  first  pit  is  dug  out  again  and  the  cycle  is  repeated. 

In  other  cities  the  privy-well  system  is  largely  in  use.  This  is — 
next  to  the  midden  or  shallow  pit  just  described — ^the  most  pernicious 
system  for  the  disposal  of  excreta  that  can  be  imagined.     The  wells 


REMOVAL  OF  SEWAGE.  175 

are  dug  to  such  a  depth  as  to  reach  the  subterranean  flow  of  water, 
in  which  the  soluble  excremental  matters  are  constantly  carried  off. 
Hence  these  receptacles  rarely  fill  up  or  need  cleaning.  Eor  this 
reason  they  are  popular  with  property  owners ;  for,  next  to  the  primi- 
tive midden,  they  are  the  most  economical  of  all  the  various  methods 
adopted.  The  utter  perniciousness  of  the  system  is,  however,  plain, 
because  the  soil  for  a  considerable  distance  around  each  of  these  wells 
becomes  a  mass  of  putrid  filth,  contaminating  the  ground-water  which 
feeds  the  drinking-water  supplies  in  the  vicinity;  po. luting  also  the 
ground-air,  which  eventually  reaches  the  surface,  or  the  interior  of 
houses,  when  the  pressure  of  the  outside  atmosphere  diminishes  or 
the  ground-water  level  rises.  It  must,  therefore,  be  evident  that  the 
best  ventilating  arrangements,  or  the  most  thorough  and  consistent 
disinfection,  can  have  very  little,  if  any,  effect  in  removing  the  very 
grave  objections  to  this  baneful  system. 

The  privy-well  system  for  the  removal  of  excreta  cannot  be  recom- 
'mended  for  adoption  by  any  sanitarian. 

2.  The  Rochdale,  or  Pail-closet  System. — The  Eochdale  system 
of  removal  of  excreta  has  won  the  support  of  many  distinguished 
sanitarians  on  account  of  its  simplicity,  its  economy,  and  its  com- 
pliance with  most  sanitary  requirements.  The  excreta,  both  solid 
and  liquid,  are  received  into  a  water-tight  pail,  either  of  wood  or 
metal,  and  removed  once  or  oftener  a  week,  a  clean  and  disinfected 
pail  being  substituted  for  the  one  removed.  In  Eochdale,  Manchester, 
and  Glasgow  in  Great  Britain,  in  Heidelberg  in  Germany,  and 
in  other  cities  abroad,  where  this  system  has  been  introduced, 
it  has  worked  satisfactorily.  In  this  country  a  modification 
of  the  pail  system,  known  as  the  Eagle  Sanitary  Closet,  has  been  in- 
troduced by  a  firm  in  Charleston,  S.  C.  The  receptacle  consists  of 
an  enameled-iron  reservoir,  with  a  neck  just  large  enough  to  fit  under 
the  seat  of  the  privy,  and  a  quantity  of  disinfectant  solution  is  put 
into  the  receptacle  to  prevent  putrefaction  of  the  excreta.  The  re- 
ceptacles are  replaced  by  clean  ones  every  week. 

Mr.  James  T.  Gardner,  Director  of  the  New  York  State  Sanitary 
Survey,  says,  in  a  special  report  on  methods  of  sewerage  applicable 
in  small  towns  and  villages,  concerning  the  pail  system^ : — 

"Eochdale  is  a  city  of  some  70,000,  and  Manchester  of  between 
400,000  and  500,000  inhabitants.  The  higher  class  of  houses  are  al- 
lowed to  have  water-closets,  but  four-fifths  of  the  people  are  obliged 

^  Second  Annual  Report  of  New  York  State  Board  of  Health,  pp.  322, 
and  323. 


176  TEXT-BOOK  OF  HYGIENE. 

to  have  'pail-closets'  in  their  yards  built  according  to  plans  of  the 
Health  Department.  Their  essential  features  are :  A  flag-stone  floor, 
raised  a  few  inches  above  the  level  of  the  yard ;  a  hinged  seat,  with  a 
metal  rim  underneath  for  directing  urine  into  the  pail,  which  stands 
on  the  flag  directly  beneath  the  seat;  a  hinged  front  and  back  to 
the  seat,  so  that  the  pail  or  tub  may  be  easily  taken  out  and  the  place 
cleaned;  and  a  6-inch  ventilating  pipe  from  under  the  seat  to  above 
the  roof.  In  Eochdale  they  use  a  wooden  pail  or  tub  made  of  half 
of  a  disused  paraffine  cask,  holding  about  40  kilogranuiies ;  in  Man- 
chester the  'pail'  is  of  galvanized  iron  and  holds  40  litres.  Under  the 
direction  of  the  authorities,  they  are  removed  once  a  week  in  covered 
vans,  which  bring  clean  tubs  to  be  put  in  the  place  of  the  full  ones 
taken  away.  Each  tub  is  covered  with  a  close-fitting  double  lid  before 
removal.  The  tubs  are  taken  to  a  depot,  where  their  contents  are 
deodorized  and  prepared  as  manure  by  mixing  with  ashes  and  a  small 
proportion  of  gypsum  to  fix  the  ammonia.  Subsequently,  street- 
sweepings  and  the  refuse  of  slaughter-houses  are  added.  At  Man- 
chester there  is  by  the  side  of  each  closet  a  very  simple  ash-sifter, 
from  which  the  ashes  fall  into  the  tub  and  help  to  deodorize  its  con- 
tents. 

"The  manure  at  Eochdale  sells  for  about  four-fifths  of  the  cost 
of  the  collection  and  preparation. 

"In  1873  the  net  cost  to  the  town  of  removing  and  disposing  of 
the  house  dry  refuse  and  excrement  was  only  about  $95  per  annum 
per  1000  of  population — less  than  10  cents  a  person  per  annum. 

"The  system  has  been  in  operation  more  than  twelve  years. 

"The  tubs  are  removed  in  the  daytime  without  offensive  odor. 

"Where  ashes  are  frequently  thrown  into  the  tubs  at  Manchester, 
very  little  odor  is  to  be  perceived  in  the  closets. 

"For  the  villages  of  the  State,  which  can  have  no  general  water- 
supply,  I  would  unhesitatingly  advise  the  use  of  the  'pail'  or  tub 
system  as  practiced  in  Manchester,  England,  as  being,  from  a  sanitary 
point  of  view,  an  immense  improvement  over  the  death-breeding  privy- 
vaults  in  common  use.  The  cheapness  of  the  plan  and  the  smallness 
of  the  original  outlay  of  brains  and  money,  in  comparison  with  that 
needed  to  build  a  good  sewer  system,  will  make  it  possible  to  introduce 
a  tub-privy  system  into  most  villages  half  a  century  before  sewers 
would  meet  with  any  consideration. 

"At  a  small  cost  the  existing  privy-vaults  can  be  cleaned  and 
filled,  and  the  privies  altered  into  healthful  tub-closets.  The  town 
authorities  must  then  arrange  for  the  removal  of  the  tubs  once  a 


REMOVAL  OF  SEWAGE. 


177 


week,  and  for  their  thorough  cleansing  and  disinfecting.  Any  iso- 
lated house,  or  group  of  houses,  can  use  the  tub  system,  taking  care  of 
it  themselves.  If  the  jDlan  is  adopted  in  villages  it  will  doubtless 
spread  into  the  country,  and  become  the  most  powerful  means  of 
abolishing  the  fatal  privy-vaults  which  are  poisoning  the  farm-wells." 
3.  Earth-  and  Ash-  Closets. — The  earth-  and  ash-  closets  are 
devices  in  use  to  a  large  extent  in  England,  and  to  a  less  degree  in 
this  country,  for  the  purpose  of  rendering  human  excreta  inodorous 
by  covering  them  immediately  after  they  are  voided  with  dry  earth 


115^."^-.    -"f 


Fig.   11. 

Fig.  11. — Pull-up  Handle  Commode,  Showing  the  Door  Open  for 
Removing  Pail.  The  flap  of  the  seat  and  earth  reservoir  are  also 
partially  raised  to  show  the  construction. 

Fig.  12. — Showing  the  Apparatus  Mounted  on  Bearers  as  when 
Fixed.      Seat  removed,  showing  mechanical  arrangement. 


or  ashes.  The  earth-closet  is  the  invention  of  the  Eev.  Henry 
Moule,  of  England,  and  consists  of  an  ordinary  commode  or  closet, 
the  essential  feature  of  which  is  a  reservoir  containing  dried  earth 
or  ashes,  a  quantity  of  which,  amounting  to  about  twice  the  quantity 
of  feces  voided,  is  thrown  upon  the  evacuation  either  by  hand  or  by 
means  of  an  automatic  apparatus  called  a  "chucker."  Just  as  in 
the  ordinary  water-closet,  by  raising  a  handle  a  supply  of  water  is 
thrown  into  a  hopper  to  wash  down  the  feces  into  the  soil-pipe,  so,  in 
the  usual  form  of  tlie  earth-closet,  raising  the  handle  projects  a  quan- 


178 


TEXT-BOOK  OF  HYGIENE. 


tity  of  earth  upon  the  evacuated  feces  and  urine.  By  this  means  the 
excreta  are  rendered  entirely  inodorous  and  dry.  The  contents  of 
the  closets  may  be  collected  into  a  heap  in  a  dry  place.     In  the 


course  of  a  few  months  the  organic  constituents  have  become  oxi- 
dized, and  the  earth  may  be  used  over  again  for  a  number  of  times. 
A  well-known  sanitarian  states  that  he  has  used  sifted  anthracite 
coal-ashes  ten  or  twelve  times  over  in  the  course  of  three  years. 
During  this  time  the  material  under  no  circumstances  gave  any  indi- 


REMOVAL  OF  SEWAGE.  I79 

cation  that  it  was  "anything  but  ashes,  with  a  slight  admixture  of 
garden-soil."^ 

Dr.  Buchanan,  of  England,  comparing  the  advantages  of  the 
earth-closet  with  those  of  the  water-closet,  says :  "It  is  cheaper  in 
original  cost;  it  requires  less  repairs;  it  is  not  injured  by  frost;  it 
is  not  damaged  by  improper  substances  being  thrown  down  it;  and  it 
very  greatly  reduces  the  quantity  of  water  required  by  each  house- 
hold."^ 

In  cities  and  towns  the  removal  of  the  excreta  should  be  carried 
out  by  or  under  the  immediate  direction  of  the  municipal  sani- 
tary authorities.  If  this  is  neglected,  abuses  are  liable  to  creep  in 
which  will  vitiate  the  performance  of  any  system,  however  faultless 
when  properly  managed. 

Many  advocates  of  the  pail,  dry  earth,  or  privy  systems  urge  the 
advantage  of  the  large  quantity  of  valuable  manure  which  can  be 
realized  by  converting  the  excremental  matters  into  poudrette  and 
other  fertilizing  compounds.  Experience  has  shown,  however,  that 
the  cost  of  preparing  a  satisfactory  fertilizer  from  human  excrement 
is  much  greater  than  can  be  realized  from  its  sale.  In  all  places  in 
Great  Britain  and  the  continent  of  Europe  where  it  has  been  tried 
the  decision  is  against  its  practicability.  The  agricultural  consider- 
ation should,  however,  be  a  secondary  one,  if  the  systems  mentioned 
are  economical  and  meet  the  sanitary  requirements  (which  the  privy 
system  certainly  does  not).  The  adoption  of  one  or  other  of  them 
may  be  secured  where  more  perfect  but  more  complicated  and  ex- 
pensive systems  may  be  out  of  the  question. 

4.  The  Pneumatic  System  of  Liernur. — A  system  which  seems 
to  be  useful  in  larger  cities,  especially  where  the  topographical  condi- 
tions are  such  as  to  render  necessary  mechanical  aid  in  overcoming  ob- 
stacles to  natural  drainage,  is  the  pneumatic  system  devised  by  Captain 
Liernur,  of  Holland,  and  generally  known  as  the  Liernur  system.  It 
consists  of  a  set  of  soil-pipes  running  from  the  water-closets  to  cen- 
tral district  reservoirs,  from  which  the  air  is  exhausted  at  stated 
intervals.  When  a  vacuum  is  created  in  the  reservoir  the  contents  of 
the  water-closets  and  soil-pipes  are  driven  forcibly  into  the  reservoir 
by  the  pressure  of  air.  The  district  reservoirs  are  connected  by  a 
separate  system  of  pipes  with  a  main  depot,  and  the  transfer  of  the 
fecal  matter  from  the  former  to  the  latter  is  also  accomplished  with 

''■  Thfi  Sanitary  Drainage  of  Houses  and  Towns,  Waring,  p.  250.  2d  ed., 
1881. 

*  Quoted  in  Waring,  above  cited,  p.  264. 


180  TEXT-BOOK  OF  HYGIENE. 

the  aid  of  pneumatic  pressure.  The  complete  system  of  Liernur 
provides  that  at  the  main  depot  the  fecal  matter  shall  be  treated  with 
chemicals,  evaporated,  and  converted  into  a  dry  fertilizer — poudrette. 
It  appears  from  the  published  reports  that  while  the  system  has  been 
partially  adopted  in  three  Dutch  cities,  in  only  one  of  them,  Dor- 
trecht,  has  the  machinery  for  manufacturing  poudrette  been  estab- 
lished. With  reference  to  this  Erismann*  says :  "It  seems  never 
to  have  been  in  regular  working  order,  for  the  fecal  masses  are  mixed 
with  street-sweepings  and  ashes  into  a  compost-mass  which  causes  no 
little  discomfort  in  the  neighborhood  by  the  offensive  odors.  In 
Amsterdam  the  fecal  matters,  which  frequently  do  not  find  a  ready 
sale,  are  partly  made  into  a  compost  with  sweepings,  partly  used  to 
fertilize  meadows,  or  simply  discharged  into  the  water." 

As  to  the  practical  working  of  the  system  the  opinions  differ 
widely.  While  the  majority  of  sanitarians,  including  Virchow,  von 
Pettenkofer,  and  Mr.  Eawlinson,  objected  to  it  as  not  fulfilling  the 
demands  of  hygiene,  the  system  has  also  been  criticized  by  engineers 
as  not  being  in  accordance  with  the  well-known  principles  of  their 
science.^ 

Two  other  plans  for  the  removal  of  fecal  matter  by  pneumatic 
pressure  have  been  invented,  namely,  the  Shone  and  the  Berlier  sys- 
tems. Neither  of  these  has  been  adopted  to  any  considerable  extent. 
Both  seem  to  the  author  to  fall  far  short  even  of  the  merits  of  the 
Liernur  system. 

5.  The  "Water-carriage  System  of  Sewerage. — Two  systems  of 
removal  of  sewage  by  water-carriage  are  in  use  at  the  present  time. 
They  are  technically  known  as  the  "combined"  and  the  "separate" 
systems.  In  the  former,  which  is  the  system  upon  which  the  most 
of  the  sewers  in  this  country  are  constructed,  all  excreta,  kitchen- 
slops,  waste-water  from  baths  and  manufacturing  establishments,  as 
well  as  storm-water,  are  carried  off  in  the  same  conduits.  In  the 
separate  system,  on  the  other  hand,  the  removal  of  the  storm-water 
is  provided  for,  either  by  surface  or  underground  drains,  not  con- 
nected with  the  sewers  proper,  in  which  only  the  discharge  from 
water-closets  and  the  refuse-water  from  houses  and  factories  are 
conveyed.    In  the  separate  system  the  pipes  are  of  such  small  calibre 


*Von  Pettenkofer  und  Ziemssen:  Handbuch  der  Hygiene.  II  Th.,  II 
Abth.,  1  Hefte,  p.  140. 

^Papers  by  Maj.  C.  H.  Latrobe  and  Col.  Geo.  E.  "Waring,  Jr.,  in  Fifth 
Biennial  Report  Md.  State  Board  of  Health.  See  also,  in  favor  of  system,  a 
paper  by  Dr.  C.  W.  Chancellor,  in  same  publication,  and  an  elaborate  descrip- 
tion by  the  same  author  in  Trans.  Med.  and  Chir.  Facidty  of  Md.,  1883. 


KEMOVAL  OF  SEWAGE.  181 

that  a  constant  flow  of  their  contents  is  maintained,  preventing 
deposition  of  suspended  matters  and  diminishing  decomposition  and 
the  formation  of  sewer-gas. 

In  the  combined  system,  on  the  other  hand,  the  sewers  must  be 
made  large  enough  to  receive  the  maximum  rain-fall  of  the  district. 
This  requires  a  calibre  greatly  in  excess  of  the  ordinary  needs  of  the 
sewer,  and  furnishes  favorable  conditions  for  the  formation  of  sewer- 
gas  and  the  development  of  minute  vegetable  organisms.  The  ordi- 
nary flow  in  a  sewer  of  large  calibre  is  usually  so  sluggish  as  to 
promote  the  deposition  of  solid  matters  and  the  gradual  obstruction 
of  the  sewer. 

It  is  the  opinion  of  the  most  advanced  sanitarians  that  the  sepa- 
rate system  fulfills  the  demands  of  a  rational  system  of  sewerage 
better  than  any  other  at  present  in  use. 

The  separate  system  of  sewage,  indorsed  as  it  is  by  high  engi- 
neering and  sanitary  authorities,  and  by  a  satisfactory,  practical  test 
in  the  city  of  Memphis  and  in  the  town  of  Keene,  IST.  H.,  seems  to 
the  author  to  possess  merits  above  any  other  plan  for  the  removal  of 
excreta  and  house-wastes.  The  following  description  is  from  a  paper 
by  Colonel  George  E.  Waring,  Jr. :  "A  perfect  system  of  sanitary 
sewerage  would  be  something  like  the  following:  ISTo  sewer  should 
be  used  of  a  smaller  diameter  than  6  inches  (15  centimetres)  :  a,  be- 
cause it  will  not  be  safe  to  adopt  a  smaller  size  than  4-inch  (10  centi- 
metres) for  house-drains,  and  the  sewer  must  be  large  enough  to 
remove  whatever  may  be  delivered  by  these ;  &,  because  a  smaller  pipe 
than^ 6-inch  would  be  less  readily  ventilated  than  is  desirable;  c,  and 
because  it  is  not  necessary  to  adopt  a  smaller  radius  than  3  inches  (5 
centimetres)  to  secure  a  cleansing  of  the  channel  by  reasonably 
copious  flushing. 

"No  sewer  should  be  more  than  6  inches  (15  centimetres)  in 
diameter,  until  it  and  its  branches  have  accumulated  a  sufficient  flow 
at  the  hour  of  greatest  use  to  fill  this  size  to  half  full,  because  the 
use  of  a  larger  size  would  be  wasteful,  and  because  when  a  sufficient 
ventilating  capacity  is  secured,  as  it  is  in  the  use  of  a  6-inch  pipe,  the 
ventilation  becomes  less  complete  as  the  size  increases,  leaving  a 
larger  volume  of  contained  air  to  be  moved  by  the  friction  of  the 
current,  or  by  extraneous  influences,  or  to  be  acted  upon  by  changes 
of  temperature  and  volume  of  flow  within  the  sewer. 

"The  size  should  be  increased  gradually,  and  only  so  rapidly  as 
is  made  necessary  by  the  filling  of  the  sewer  half  full  at  the  hour 
of  greatest  flow. 


182  TEXT-BOOK  OF  HYGIENE. 

"Every  point  of  the  sewer  should,  by  the  use  of  gaskets  or  other- 
wise, be  protected  against  the  intrusion  of  cement,  which,  in  spite 
of  the  greatest  care,  creates  a  roughness  tliat  is  liable  to  accumulate 
obstructions. 

"The  upper  end  of  each  branch  sewer  should  be  provided  with 
a  Field's  flush-tank  of  sufficient  ca^Dacity  to  secure  the  thorough 
daily  cleansing  of  so  much  of  the  conduit  as  from  its  limited  flow  is 
liable  to  deposit  solid  matters  by  the  way. 

"There  should  be  sufficient  man-holes,  covered  by  open  gratings, 
to  admit  air  for  ventilation.  If  the  directions  already  given  are  ad- 
hered to,  man-holes  will  not  be  necessary  for  cleansing.  The  use  of 
the  flush-tank  will  be  a  safegiiard  against  deposit.  With  the  system 
of  ventilation  about  to  be  described,  it  will  suffice  to  place  the  man- 
holes at  intervals  of  not  less  than  1000  feet  (305  metres). 

"For  the  complete  ventilation  of  the  sewers  it  should  be  made 
compulsory  for  every  householder  to  make  his  connection  without 
a  trap,  and  to  continue  his  soil-pipe  above  the  roof  of  the  house. 
That  is,  every  house  connection  should  furnish  an  uninterrupted 
ventilation-channel  4  inches  (10  centimetres)  in  diameter  through- 
out its  entire  length.  This  is  directly  the  reverse  of  the  system  of 
connection  that  should  be  adopted  in  the  case  of  storm-water  and 
street-wash  sewers.  These  are  foul,  and  the  volume  of  their  contained 
air  is  too  great  to  be  thoroughly  ventilated  by  such  appliances.  Their 
atmosphere  contains  too  much  of  the  impure  gases  to  make  it  pru- 
dent to  discharge  it  through  house-drains  and  soil-pipes.  With  the 
system  now  described,  the  flushing  would  be  so  constant  and  com- 
plete and  the  amount  of  ventilation  furnished,  as  compared  to  vol- 
ume of  air  to  be  changed,  would  l)e  so  great,  that  what  is  popularly 
known  as  'sewer-gas'  would  never  exist  in  any  part  of  the  public 
drains.  Even  the  gases  produced  in  the  traps  and  pipes  of  the  house 
itself  would  be  amply  rectified,  diluted,  and  removed  by  the  con- 
stant movement  of  air  through  the  latter. 

"All  house  connections  with  the  sewers  should  be  through  in- 
lets entering  in  the  direction  of  the  flow,  and  these  inlets  should  be 
funnel-shaped  so  that  their  flow  may  be  delivered  at  the  bottom  of 
the  sewer,  and  so  that  they  may  withdraw  the  air  from  its  crown; 
that  is,  the  vertical  diameter  of  the  inlet  at  its  point  of  junction 
should  be  the  same  as  the  diameter  of  the  sewer. 

"All  changes  of  direction  should  be  on  gradual  curves,  and,  as 
a  matter  of  course,  the  fall  from  the  head  of  each  branch  to  the  out- 


REMOVAL  OF  SEWAGE,  183 

let  should  be  continuous.  Eeduction  of  grade  within  this  limit,  if 
considerable,   should  always  be  gradual. 

"So  far  as  circumstances  will  allow,  the  drains  should  be  brought 
together,  and  they  should  finally  discharge  through  one  or  a  few  main 
outlets. 

"The  outlet,  if  water-locked,  should  have  ample  means  for  the 
admission  of  fresh  air.  If  open,  the  mouth  should  be  protected 
against  the  direct  action  of  the  wind. 

"It  will  be  seen  that  the  system  of  sewerage  here  described  is 
radically  different  from  the  usual  practice.  It  is  cleaner,  is  much 
more  completely  ventilated,  and  is  more  exactly  suited  to  the  work  to 
be  performed.  It  obviates  the  filthy  accumulation  of  street-manure 
in  catch-basins  and  sewers,  and  it  discharges  all  that  is  delivered 
to  it  at  the  point  of  ultimate  outlet  outside  the  to^^vn  before  decom- 
position can  even  begin.  If  the  discharge  is  of  domestic  sewage  only, 
its  solid  matter  will  be  consumed  by  fishes  if  it  is  delivered  into  a 
water-course,  and  its  dissolved  material  will  be  taken  up  by  aquatic 
vegetation. 

"The  limited  quantity  and  the  uniform  volume  of  the  sewage, 
together  with  the  absence  of  dilution  by  rain-fall,  will  make  its  dis- 
posal by  agricultural  or  chemical  processes  easy  and  reliable. 

"The  cost  of  construction,  as  compared  with  that  of  the  most 
restricted  storm-water  sewers,  will  be  so  small  as  to  bring  the  im- 
provement within  the  reach  of  the  smaller  communities. 

"In  other  words,  while  the  system  is  the  best  for  large  cities, 
it  is  the  only  one  that  can  be  afforded  in  the  case  of  small  towns. 

"Circumstances  are  occasionally  such  as  to  require  extensive  en- 
gineering works  for  the  removal  of  storm-water  through  very  deep 
channels.  Ordinarily,  the  removal  of  storm-water  is  a  very  simple 
matter,  if  we  will  accept  the  fact  that  it  is  best  carried,  so  far  as 
possible,  by  surface  gutters,  or,  in  certain  cases,  by  special  con- 
duits, placed  near  the  surface. 

"It  is  often  necessary,  in  addition  to  the  removal  of  house-waste, 
to  provide  for  the  drainage  of  the  subsoil.  This  should  not  be  ef- 
fected by  open  joints  in  the  sewers;  because  the  same  opening  that 
admits  soil-water  may,  in  dry  seasons  and  porous  soils,  permit  the 
escape  of  sewage  matters  into  the  ground,  which  is  always  objec- 
tionable. 

"Soil-water  drains  may  be  laid  in  the  same  trench  with  the 
sewers,  but  preferably,  unless  they  have  an  indepenrlent  outlet,  on  a 
shelf  at  a  higher  level.     When  they  discharge  into  the  sewer  they 


184  TEXT-BOOK  OF  HYGIENE. 

should  always  deliver  into  its  upper  part,  or  into  a  man-hole  at  a 
point  above  the  flow-line  of  the  sewage.'"^ 

The  establishment  of  a  system  of  sewerage  presupposes  a  con- 
stant and  abundant  supply  of  water  to  keep  all  closets  clean  and  all 
house-drains  and  street-sewers  well  flushed.  Where  this  cannot  be 
obtained,  sewers  would  be  likely  to  prove  greater  evils  than  benefits. 
In  such  cases  one  of  the  methods  of  removal  of  excreta  before  men- 
tioned, either  the  pail-  or  earth-  closet  system,  should  be  adopted. 

The  final  disposal  of  sewage  is  a  problem  that  depends  for  its 
solution  partly  upon  the  agricultural  needs  of  the  country  around 
the  city  to  be  sewered,  partly  upon  the  proximity  of  large  bodies  of 
water  or  running  streams.  When  the  city  is  situated  upon  or  near 
large  and  swiftly-flowing  streams,  the  sewage  may  be  emptied  di- 
rectly into  the  stream  without  seriously  impairing  the  purity  of  the 
latter,  although  the  principle  of  thus  disposing  of  sewage  is  wrong. 
Dilution,  deposition,  and  oxidation  will  soon  remove  all  appreciable 
traces  of  the  sewage  of  even  the  largest  cities.  Where,  on  the  other 
hand,  the  stream  is  inadequate  in  size  to  carry  off  the  sewage,  or 
where,  as  in  the  Seine  and  Thames,  the  current  is  sluggish,  some 
other  method  of  final  disposal  must  be  adopted. 

In  many  cities  of  Great  Britain  and  the  continent  of  Europe  the 
disposal  of  the  sewage  by  irrigation  of  cultivated  land  has  been  prac- 
ticed for  a  number  of  years.  The  reports  upon  the  working  of  the 
system  are  generally  favorable,  although  some  sanitarians  express 
doubts  of  the  efficiency  of  the  system.  In  using  sewage  for  the  irriga- 
tion of  land,  two  objects  are  secured:  first,  the  fertilization  of  the 
land  by  the  manurial  constituents  of  the  sewage,  and  second,  the 
purification  of  the  liquid  portion  by  filtration  through  the  soil.  The 
organic  matters  which  have  been  held  back  by  the  soil  undergo  rapid 
oxidation  in  the  presence  of  air  and  the  bacteria  of  decay,  and  are 
converted  into  plant-food,  or  into  harmless  compounds.  Sewage  irri- 
gation, as  practiced  in  Europe,  must  make  provision  for  the  disposal 
of  a  very  large  proportion  of  water  in  the  sewage  (street-wash,  storm- 
water),  which  requires  much  larger  areas  of  land  than  would  be 
needed  if  only  sewage  material  proper  (water-closet  and  kitchen-waste) 
was  thus  to  be  disposed  of.  Eecent  experiments  have  shown  that  the 
purification  of  sewage  is  a  biological  process  depending  on  the  action 
of  bacteria. 


'  The  Sewering  and  Drainage  of  Cities,  Waring,  Public  Health,  vol.  v,  p.  35. 


REMOVAL  OF  SEWAGE. 


185 


The  more  important  bacteria  found  in  sewage  are'^ : — 

OBLIGATORY   AXAEEOBES. 

Spirillum  7'ugula. — Gives  rise  to  fecal  odor. 
Spirillum  amyliferum. — Acts  as  a  vigorous  ferment. 
Bacillus  hiityricus. — Gives  rise  to  much  gas. 

FACULTATIVE  ANAEROBES,  OR  AEROBES. 

Bacillus  putrificus  coli. — Decomposes  albuminous  substances, 
with  liberation  of  ammonia. 

Bacillus  mycoides.  proteus  vulgaris. — Produces  ammonia  from 
nitrogenous  matter  and  denitrification. 

Bacillus   fluorescens   putridus. — Produces    trimethylamine. 

Micrococcus  urece. — Converts  urea  into  ammonium  carbonate. 

Bacillus  lactis  a'ero genes. — Produces  carbon  dioxide  and  hydrogen. 

Bacillus  coli  communis. — Produces  gas,  chiefly  hydrogen. 

Bacillus  suhtilis. — Eapidly  consumes  oxygen. 

Proteus  sulphureus. — Produces  hydrogen  sulphide  and  mercaptan. 

Bacillus  sulpJiureum. — Liquefies  gelatin  and  casein  and  produces 
hydrogen  sulphide. 

In  addition,  several  other  species  of  bacteria  are  present  in  sew- 
age, the  action  of  which  is  not  definitely  loiown.  Of  disease-producing 
bacteria,  bacillus  cholerse,  bacillus  dysenterise  (Shiga),  bacillus  ty- 
phosus, streptococci,  and  staphylococci  have  been  found. 

These  bacteria  produce  certain  changes  in  the  organic  matter, 
resolving  the  highly  complex  organic  molecules  into  simple  inorganic 
compounds. 

The  changes  taking  place  in  sewage  are  as  follows  (Eideal)  : — 


Table  XXVII. 


Initial 
Transient  aerobic  changes 
by  the   oxygen    of    the 
water     supply     rapidly 
passing  to  : 

FiEST  Stage 

Anerobic  liquefaction  and 
preparation  by  hydroly- 


Substances  dealt  with 


Urea,  Ammonia,  and  easily 
decomposable  matters. 


Albuminous  matters .  Cel- 
lulose and  fibre  fats. 


Characteristic  Products 


Soluble  nitrogenous  com- 
pounds. Phenol  deriva- 
tives. Gases.  Ammo- 
nia. 


^  Sewage  and  the  Bacterial  Purification  of  Sewage.    S.  Rideal,  1901. 


186 


TEXT-BOOK  OF  HYGIENE. 


Table  XXVII. — (  Continued). 


Second  Stage 
Semi-anerobic  breaking 
down  of  the  intermedi- 
ate dissolved  bodies. 


Thied  Stage 
Complete   aeration  :  nitri- 
fication. 


Substances  dealt  with 


Amido  compounds.  Fatty 
acids.  Dissolved  resi- 
dues.     Phenolic  bodies. 


Ammonia     and    carbona- 
ceous residues. 


Characteristic  Products 


Ammonia.  Nitrites.  Gases. 


Carbon  dioxide,  water,  and 
nitrates. 


Based  on  these  principles,  various  methods  of  purification  of 
sewage  have  been  adopted. 

1.  Broad  Irrigation. — This  method  is  defined  by  the  Eoyal  Com- 
mission on  Metropolitan  Sewage  Discharge  as  "the  distribution  of 
sewage  over  a  large  surface  of  ordinary  agricultural  land,  having  in 
view  a  maximum  growth  of  vegetation  (consistent  with  due  purifi- 
cation) for  the  amount  of  sewage  supplied." 

2.  Irrigation  with  Copious  TJnderdrainage. — This  method  is  de- 
fined as  "the  concentration  of  sewage,  at  short  intervals,  on  an  area 
of  specially-chosen  porous  ground,  as  small  as  will  absorb  and  cleanse 
it ;  not  excluding  vegetation,  but  making  the  produce  of  secondary  im- 
portance." 

3.  Sedimentation  or  Chemical  Precipitation,  Followed  by  Broad 
Irrigation  or  Filtration. — In  this  system  the  sewage  is  precipitated 
by  lime  or  iron  sulphate,  the  precipitate  allowed  to  settle,  and  the 
supernatent  liquid  is  distributed  over  large  areas  of  land  or  made  to 
pass  through  sand  filters.  The  latter  method  is  employed  successfully 
in  Worcester,  Mass.  However,  the  difficulty  of  disposing  of  the  sedi- 
ment, or  "sludge,"  is  quite  serious  and  greatly  impairs  the  utility  of 
the  system. 

4.  Sterilization  by  Heat  and  Disinfection. — These  methods,  while 
no  doubt  the  most  efficient,  are  not  practical  on  a  large  scale. 

5.  Bacterial  Purification. — This  system,  otherwise  known  as  the 
"septic  tank"  method,  is  the  outcome  of  a  series  of  experiments  made 
since  1865,  which  proved  that  the  disintegration  and  final  purifica- 
tion of  sewage  are  due  to  the  action  of  micro-organisms.  In  1865,  Dr. 
A.  Mueller  wrote:  "The  contents  of  sewage  are  chiefly  of  organic 
origin,  and  in  consequence  of  this  an  active  process  of  decomposition 
takes  place  in  sewage,  through  which  the  organic  matters  are  gradu- 
ally dissolved  into  mineral  matters,  or,  in  short,  are  mineralized,  and 


REMOVAL  OF  SEWAGE.  187 

thus  become  fit  to  serve  as  food  for  plants.  To  the  superficial  observer 
this  process  appears  to  be  a  chemical  self-reduction;  in  reality,  how- 
ever, it  is  chiefly  a  process  of  digestion,  in  which  the  various — mostly 
microscopically  small — animal  and  vegetable  organisms  utilize  the 
organically  fixed  power  for  their  life  purposes." 

The  "septic  tank"  is  merely  a  large  cesspool  in  which  the  sew- 
age undergoes  putrefactive  changes  brought  about  by  the  activity  of 
anaerobic  bacteria. 

"The  septic  or  bacterial  tank  may  be  built  of  concrete,  brick, 
masonry,  or  wood,  and  it  may  be  covered  or  not,  though  a  light  cov- 
ering of  boards,  to  prevent  the  wind  and  rain  breaking  up  the  sur- 
face scum,  may  be  advisable.  An  airtight  covering  is  necessary  only 
when  the  tank  is  located  in  a  portion  of  the  community  where  its 
odors  would  become  a  nuisance.  The  tanks  should  be  large  enough  to 
hold  the  sewage  of  2000  persons  for  one  day,  or  about  55,000  gallons. 
In  the  most  approved  tanks  there  arq  two  compartments,  the  first 
being  about  ten  feet  deep  by  seven  feet  long  and  eighteen  feet  wide 
and  known  as  the  ^grit  chamber,'  as  it  is  designed  to  receive  the  grit 
and  heavier  settlings  from  the  sewage.  Into  this  the  crude  sewage  is 
led  by  two  inlet  pipes,  which  discharge  about  five  feet  beneath  the 
surface,  so  as  not  to  disturb  either  the  surface  crust  or  the  settled 
sediment.  From  this  first  chamber  the  contents  flow  through  sub- 
merged openings  in  the  partition  wall  into  the  second  compartment, 
which  is  about  seven  feet  deep,  sixty-five  feet  long,  and  of  the  same 
width  as  the  first.  The  flow  is  maintained  at  a  rate  to  take  twenty- 
four  hours  from  entrance  to  exit.  The  effluent  is  brownish  yellow 
in  color  and  more  or  less  offensive  in  odor. 

"In  the  septic  tank,  as  in  the  cesspool,  the  anaerobic  or  putre- 
factive bacteria  are  the  active  agents,  and  so  energetic  are  they  on  a 
warm  day  that  the  contents  of  the  tank  seem  fairly  to  boil,  though,  of 
course,  the  temperature  is  but  slightly  above  that  of  the  surrounding 
air.  The  microbes  penetrate  the  solids  floating  in  the  sewage,  and 
their  gaseous  products  accumulate  in  such  volume  as  to  carry  the 
solids  to  the  surface  of  the  tankage,  sometimes  with  sufficient  force  to 
project  them  through  the  overlying  crust.  It  is  this  and  the  escap- 
ing gas  which  give  the  boiling  appearance  on  a  hot  day.  The  whole 
mass  is  very  actively  at  Vork,'  and  the  process  is  identical  with 
that  which  takes  place  in  a  jar  of  forking'  apple-butter  or  pre- 
serves insufficiently  cooked  or  insufficiently  supplied  with  cane  sugar. 
In  short,  the  process  is  one  of  fermentation,  and  by  it  40  to  60  per 
cent,  of  the  organic  matter  is  removed,  while  over  the  bottom  of  the 


188  TEXT-BOOK  OF  HYGIENE. 

tank  accumulates  the  small  percentage  of  ^ash'  or  mineral  matter 
originally  combined  in  the  sewage,  amounting  to  a  deposit  of  some- 
thing over  a  foot  per  year.  The  gas  generated  is  rich  in  hydrocarbons 
and  may  be  used  for  fuel  or  illumination." 

From  the  "septic  tank"  the  sewage,  which  is  now  completely 
hydrolyzed,  is  passed  through  beds  of  either  broken  brick,  cinders, 
coke,  or  stone,  the  so-called  "contact  beds,"  or  sand,  to  which  the  term 
"filter-bed"  is  applied.  While  passing  through  these  beds,  the  re- 
maining organic  impurities  are  oxidized  by  the  aerobic  bacteria. 

The  rate  of  filtration  is  about  500,000  gallons  per  acre  per  day. 

The  resulting  effluent  is  clear,  colorless,  practically  odorless,  and 
practically  free  from  sewage  bacteria.  Such  an  effluent  may  be  safely 
emptied  into  a  stream  without  danger  of  polluting  it. 

The  "septic  tank"  treatment  of  sewage  has  been  also  employed 
for  the  purification  of  the  sewage  on  a  small  scale.  The  following 
adaptation  is  recommended  bv  the  Illinois  State  Board  of  Health® : — 

"This  plant  consists  of  two  tanks,  the  first  the  septic  tank  proper ; 
the  second,  a  discharging  tank.  The  septic  tank  is,  in  construction, 
practically  a  cistern  4  feet  in  diameter  and  about  3  feet  deep.  The 
sewage  from  the  house  enters  this  tank  through  a  lightly  trapped 
pipe,  the  flow  from  the  ordinary  household  preventing  the  back-flow 
of  air.  Across  the  center  of  the  tank  is  a  wall,  which  divides  it  into 
two  chambers  of  equal  size.  The  height  of  this  wall  is  exactly  to  the 
point  of  outflow. 

"The  sewage  from  the  house  enters  the  first  chamber  of  the  septic 
tank  with  considerable  force,  causing  some  disturbance  of  the  con- 
tents. The  flow  over  the  dividing  wall  into  the  second  chamber,  how- 
ever, is  even  and  slow,  so  that  the  contents  of  the  second  chamber  are 
not  disturl)ed,  and  the  flocculent  matter  settles  readily  to  the  bottom. 

"The  bacterial  action  on  the  contents  of  this  tank  is  often  so 
complete  that  there  is  no  appreciable  residue  or  sludge,  and  in  this 
case  the  tank  will  rarely  if  ever  have  to  be  cleaned  out.  In  some 
instances,  however,  the  tank  will  require  occasional  cleaning.  The 
sludge  from  a  well-constructed  tank  is  not  offensive,  and  may  be  dis- 
posed of  without  difficulty. 

"The  sewage  is  carried  into  the  discharging  chamber  (which  is 
a  cistern  6  feet  in  diameter  and  about  4  feet  in  depth),  through  a 
deeply  trapped  pipe.  The  second  or  discharging  tank  should  be  of 
sufficient  size  to  hold  the  overflow  from  the  septic  tank  for  a  period 


«  Bull.  No.  2,  1906. 


REMOVAL  OF  SEWAGE.  189 

of  12  to  24  hours.  At  the  bottom  of  the  discharging  tank  is  an 
automatic  siphon,  which  is  opened  automatically  when  the  efliuent 
reaches  a  certain  height  in  the  tank  or  chamber — a  height  of  about 
2^/2  feet.  Through  this  siphon  the  contents  of  the  chamber  will  pass 
'in  a  very  few  moments,  at  which  time  the  siphon  will  automatically 
close  and  the  chamber  will  again  refill. 

"From  the  siphon,  a  pipe  conducts  the  effluent  to  the  place  of 
discharge,  usually  on  a  lawn,  or  in  a  pasture  or  field. 

"The  effluent  is  usually  entirely  without  odor  and  is  inoffensive 
in  every  way.  It  may  be  discharged  upon  a  lawn,  provided  the  lawn 
is  well  under-tiled  and  drained,  or  it  may  be  emptied  into  any  stream, 
provided  the  water  from  the  stream  is  not  used  for  drinking  purposes. 
While  it  is  true  that  raw  sewage  is  frequently  directed  into  streams 
whose  water  is  used  for  domestic  purposes,  it  is  contrary  to  the  policy 
of  the  State  Board  of  Health  to  sanction  even  the  discharge  of  this 
comparatively  harmless  effluent  into  such  streams." 

A  number  of  small  septic  tank  disposal  plants  have  been  con- 
structed in  the  vicinity  of  Wilmington,  Del.,  for  the  disposal  of  the 
sewage  from  large  residences.  The  results  have  proved  quite  satis- 
factory. 

Garbag^e. — By  garbage  is  meant  refuse  from  the  kitchen.  This 
should  be  collected  in  air-tight  receptacles  and  frequently  removed  for 
final  disposal.  The  latter  may  be  effected  either  by  feeding  the 
garbage  to  hogs  or  cremation.  While  cremation  is  the  more  expen- 
sive of  the  two  processes,  it  is  also  the  more  sanitary  and  should  be 
preferred  on  that  account. 


QUESTIONS  TO  CHAPTER  V. 

REMOVAL  OF  SEWAGE. 

Why  must  arrangements  be  made  in  all  large  communities  for  the  re- 
moval of  sewage?  To  what  do  the  organic  constituents  of  sewage  give  rise, 
and  Avhat  is  the  effect  upon  health  of  the  continued  inhalation  of  these  prod- 
ucts? How  else  may  the  impregnation  of  the  soil  with  sewage  endanger 
health?  What,  then,  is  the  object  of  any  system  of  sewage  removal?  What 
will  likely  govern  the  choice  and  adoption  of  a  sewage-removal  system  by  any 
community  ? 

What  different  systems  are  in  use  at  the  present  time?  Which  of  these 
is  the  worst  and  most  unsanitary?  In  case  the  privy  system  is  to  be  con- 
sidered, what  conditions  should  be  insisted  upon?  How  may  a  pri\'y  be  ven- 
tilated? Why  should  a  privy  not  be  located  in  a  cellar  nor  too  near  the  house? 
What  substances  may  be  used  to  deodorize  the  contents  of  privy-vaults,  and 
how?  Are  deodorizers  always  disinfectants,  and  is  the  danger  necessarily 
removed  when  the  odor  is  destroyed?  How  often  should  privy-vaults  be 
emptied?  How  may  this  be  done  without  offense  to  the  senses?  What  are 
the  grave  objections  to  the  midden  or  shallow-pit  system,  and  to  digging  the 
vault  or  cess-pool  to  the  level  of  the  ground-water? 

What  is  meant  by  the  Rochdale  or  pail-closet  system?  What  are  some 
of  its  advantages?  What  can  be  said  of  its  efficacy  for  large  communities  and 
for  the  economy  of  administration?  What  is  an  earth-closet,  and  upon  what 
does  its  efficacy  depend?     What  are  some  of  its  advantages? 

Describe  the  pneumatic  system  of  Liernur.  Has  it  apparently  been  satis- 
factory in  its  workings?  What  other  systems  have  employed  the  pneumatic 
principle,  and  with  what  success? 

What  do  we  mean  by  the  water-carriage  system  of  sewerage?  What  two 
systems  are  embraced  under  this  head?  Wliat  is  the  distinction  between  the 
two?  Which  is  in  most  common  use?  What  must  be  the  size  of  the  sewers  in 
the  combined  system,  and  what  are  the  consequent  objections?  Why  does 
the  separate  system  seem  the  better?  Describe  the  latter  in  detail.  What 
governs  the  size  of  the  drains  in  the  separate  system?  How  is  this  system 
kept  clean  and  free  from  obstruction?  How  is  it  to  be  ventilated?  How  does 
it  differ  in  this  respect  from  the  combined  system?  'S^Hiat  are  some  of  the 
especial  points  to  be  observed  in  the  construction?  What  may  be  said  as  to 
cost  of  construction  and  as  to  the  ultimate  disposal  of  the  sewage?  Why 
should  sewers  not  be  employed  to  drain  the  subsoil?     How  may  this  be  done? 

What  does  the  establishment  of  a  sewerage  system  presuppose?  If 
plenty  of  water  cannot  be  had,  what  system  of  sewage  removal  should  be 
adopted  ? 

(190) 


QUESTIONS  TO  CHAPTER  V.  191 

In  what  way  maj'  we  finally  dispose  of  the  sewage?  What  are  the  objec- 
tions to  discharging  it  into  running  streams?  How  will  it  be  finally  disposed 
of  in  such  a  stream  ?  What  is  meant  by  the  irrigation,  the  sub-irrigation,  and 
the  filtration  methods?  What  becomes  of  the  organic  matter  of  the  sewage 
in  each  case?  What  of  the  sewage  water?  What  sort  of  soil  is  needed  for 
the  irrigation  method?  What  can  be  said  of  the  disposal  of  sewage  and 
garbage  by  cremation?  What  chemicals  are  used  for  the  precipitation  of 
sewage?  What  action  have  bacteria  on  sewage?  What  is  the  septic  tank 
method  of  purification  of  sewage?  How  may  this  method  be  used  on  a  small 
scale?     How  should  garbage  be  disposed  of? 


CHAPTER  VI. 

CONSTRUCTION  OF  HABITATIONS. 

The  importance  of  observing  the  principles  of  hygiene  in  the 
construction  of  habitations  for  human  beings  is  not  sufficiently  appre- 
ciated by  the  pub'ic.  Architects  and  builders  themselves  have  not 
kept  pace  with  the  sanitarian  in  the  study  of  the  conditions  necessary 
to  be  observed  in  building  a  dwelling-house  which  shall  answer  the 
requirements  of  sanitary  science. 

In  an  investigation  conducted  by  Dr.  Yillerme^  it  was  found  that 
in  France,  from  1821  to  1827,  of  the  inhabitants  of  arrondissements 
containing  7  per  cent,  of  badly-constructed  dwellings,  1  person  out 
of  every  72  died;  of  the  inhabitants  of  arrondissements  containing 
22  per  cent,  of  badly-constructed  dwellings,  1  out  of  65  died;  while 
of  the  inhabitants  of  arrondissements  containing  38  per  cent,  of 
badl3^-constructed  dwellings,  1  out  of  every  45  died. 

Inseparable  from  the  question  of  the  defective  construction  of 
dwellings  is  that  of  overcrowding  in  cities,  because  the  most  crowded 
portions  of  a  city  are  at  the  same  time  those  in  which  the  construction 
of  dwellings  is  most  defective  from  a  hygienic  standpoint.  The  fol- 
lowing tables  show  the  relations  of  the  death-rate  to  density  of  popu- 
lation in  various  large  cities  of  Europe,  and  also  the  relations  between 
overcrowding  in  dwellings  and  the  mortality  from  contagious  dis- 
eases : — 


Table  XXVIII. 

RELATION   OF   DEATH-RATE   TO    DENSITY   OE    POPULATION. 


City 

Mean  Number  of  Inhab- 
itants to  each  house 

Average  Dea'h-rate  per 
1000  Inhabitants 

London  

8 
32 
35 

52 
55 

24 

Berlin  

25 

Paris 

28 

St.  Petersburg 

41 

Vienna 

47 

^Quoted  in  Ilealencyelopaedia  d.  ges.  Heilk.,  Bd.  ii,  71. 
(192) 


CONSTRUCTION  OF  HABITATIONS.  193 

In  Glasgow,  the  death-rate  in  apartments  with  1.31  occupants 
is  21.7  per  1000,  while  in  apartments  with  2.05  occupants  the  rate  is 
28.6  per  1000. 

In  Buda-Pesth,  in  1872-73,  it  was  found  that  out  of  every  100 
deaths  from  all  causes  there  were,  from  contagious  diseases : — 

20  deaths  in  dwellings  with  1   to     2  persons  in  each  room. 

29  "        "  "               "  3    "      5         "  "       " 

32  "        "  "              "  6    "     10        "  "       " 

79  "        "  "              "  over  10        "  "       "         " 

Dr.  Jose  A.  de  los  Eios  gives  the  following  statistics,  bearing 
upon  the  mortality  of  cholera,  in  relation  to  the  number  of  persons 
occupying  one  room  when  attacked  by  it : — 

Of  10,000  persons  attacked  by  cholera,  and  living- 1  person  to  the 
room,  68  died. 

Of  10,000  persons  attacked  by  cholera,  from  1  to  2  to  the  room, 
131  died. 

Of  10,000  persons  attacked  by  cholera,  living  2  to  4  to  the  room, 
219  died. 

Of  10,000  persons  attacked  by  cholera,  living  4  or  more  to  the 
room,  327  died. 

These  figures  show  very  clearly  the  vital  importance  of  the  appli- 
cation of  sanitary  laws  in  the  construction  and  occupation  of  dwell- 
ings. 

The  direct  relation  of  overcrowding  to  pulmonary  tuberculosis 
has  been  firmly  established  by  recent  statistics,  ISTot  only  do  the 
absence  of  light,  air,  and  sunshine  usually  found  in  overcrowded  tene- 
ments favor  the  long  life  of  the  tubercle  bacillus,  but  the  aggregation 
of  people,  many  of  whom  are  tuberculous,  tends  to  a  rapid  dissemi- 
nation of  the  disease.  The  tuberculosis  problem  will  never  be  satis- 
factorily solved  so  long  as  the  housing  of  the  poor  will  remain  in  the 
wretched  condition  in  which  we  see  it  to-day  in  large  cities. 

Another  curious  and  suggestive  point  is  presented  by  some  statis- 
tical researches  on  the  mortality  of  Berlin,  in  regard  to  the  death- 
rate  among  persons  living  in  different  stories  of  houses.  It  was 
found,  for  example,  that  the  mortality  in  fourth-story  dwellings  is 
higher  than  in  the  lower  stories.  Even  basement  dwellings  furnish 
a  lower  death-rate.  Still-births,  especially,  occur  in  a  larger  propor- 
tion among  the  occupants  of  the  upper  stories  of  houses.  This  may 
be  explained  by  the  unfavorable  effects  of  frequent  stair-climbing, 
especially  on  pregnant  women. 


194 


TEXT-BOOK  OF  HYGIENE. 


It  is  in  the  death-rate  among  young  children  that  the  effects  of 
overcrowding  and  unsanitary  construction  of  dwellings  are  especially 
manifest.  The  mortality  returns  from  all  the  large  cities  of  the  world 
give  mournful  evidences  of  this  every  summer. 

The  researches  of  Dr.  H.  I.  Bowditch  upon  soil-wetness,  to  which 
reference  has  already  been  made  in  a  previous  chapter,  show  conclu- 
sively that  persons  living  in  houses  situated  upon  or  near  land  habit- 
ually or  excessively  wet,  are  especially  prone  to  be  attacked  by  pul- 
monary consumption.  Dr.  Buchanan-  has  corroborated  the  truth  of 
Dr.  Bowditch's  observations  by  ehowing,  from  the  records  of  a  num- 
ber of  cities  and  towns  of  Great  Britain,  that,  with  the  introduction 
of  a  good  drainage  system,  bringing  about  a  depression  and  uniformity 
of  level  of  the  ground-water,  the  mortality  from  consumption  and 
other  diseases  very  markedly  diminished.  The  following  table,  show- 
ing the  proportionate  amount  of  this  diminution,  is  abridged  from  the 
official  reports^ : — 

Table  XXIX. 

RESULTS  OF   SANITARY  W^ORK. 


Name  of  Place. 


a 

a 

ll 

P. 

<2 

Average  Mor- 
tality per  lOOO 
bnfore  Con- 
struction of 
Works 

Average  Mor- 
tality per  1000 
since  Comple- 
tion of  Works 

«2 

o  g 

Reduction  of 

Typhoid  Fever 

Rate 

(per  cent.) 

10,238 

23.4 

20.5 

12.1 

48 

33,954 

33  2 

22.6 

32 

40 

30,229 

23  7 

18.6 

22 

63 

23,108 

22  6 

20.9 

7 

36 

7,847 

23.9 

20.5 

14 

56 

68,056 

26  4 

25.2 

41- 

48 

27,475 

29.8 

23.7 

20 

48 

52,778 

33.2 

26.2 

18 

60 

24,756 

31.8 

21.6 

32 

36 

7,818 

19.1 

18.6 

2} 

10 

9,030 

27.5 

21.9 

20 

75 

10,570 

22.7 

21.0 

n 

52 

Banbnry  .  . 
Cardiff  .... 
Croydon  . , . 

Dover 

Ely 

Leicester . . . 
Macclesfield 
Merthyr  . . . 
Newport   . . 

Rugby 

Salisbury  . . 
Warwick  . . 


41 
17 
17 
20 
47 
32 
31 
11 
32 
43 
49 
19 


The  following  must  be  taken  into  account  in  building  a  house  in 
accordance  with  sanitary  principles: — 


I.    SITE. 

The   building-site    should    be    protected    against   violent   winds, 
although  a  free  circulation  of  air  all  around  the  house  must  be  se- 


'  Ninth  and  Tenth  Reports  of  the  medical  officer  to  the  Privy  Council. 
'  Sanitary  Engineering,  Baldwin  Latham,  p.  2.     Chicago,  1877. 


CHARACTER  OF  THE  SOIL.  195 

cured.  Close  proximity  to  cemeteries,  marshes,  and  injurious  manu- 
facturing establishments  or  industries  must  be  avoided  if  possible.  A 
requisite  of  the  highest  importance  is  the  ability  to  command  an 
abundant  supply  of  pure  water  for  drinking  and  other  purposes.  A 
neglect  of  this  precaution  will  be  sure  to  result  to  the  serious  incon- 
venience, if  not  detriment,  of  the  occupants  of  the  house. 

II.    CHARACTER  OF  THE  SOIL. 

The  soil  should  be  porous  and  free  from  decomposing  animal  or 
vegetable  remains,  or  excreta  of  man  or  animals.  It  should  be  freely 
permeable  to  air  and  water,  and  the  highest  level  of  the  ground-water 
should  never  approach  nearer  than  3  metres  to  the  surface.  The  fluc- 
tuations of  the  ground-water  level  should  be  limited.  In  this 
connection,  attention  is  again  called  to  the  aphorism  of  Dr.  De- 
Chaumont.* 

It  is  impossible  to  say  positively  that  any  kind  of  soil  is  either 
healthy  or  unhealthy,  merely  from  a  knowledge  of  its  geological  char- 
acters. The  accidental  modifying  conditions  above  referred  to,  viz., 
organic  impurities,  moisture,  the  level  and  fluctuations  of  the  ground- 
water, are  of  much  greater  importance  than  mere  geological  formation. 
The  late  Dr.  Parkes,  however,  regarded  the  geological  structure  and 
conformation  as  of  no  little  importance,  and  summarized  the  sani- 
tary relations  of  soils,  variously  constituted,  as  follows^ : — 

"1.  The  Granitic,  Metamorphic,  and  Trap  Rocks. — Sites  on  these 
formations  are  usually  healthy;  the  slope  is  great,  water  runs  off 
readily;  the  air  is  comparatively  dry;  vegetation  is  not  excessive; 
marshes  and  malaria  are  comparatively  infrequent;  and  few  im- 
purities pass  into  the  drinking-water. 

"When  these  rocks  have  been  weathered  and  disintegrated  they 
are  supposed  to  be  unhealthy.  Such  soil  is  absorbent  of  water;  and 
the  disintegrated  granite  of  Hong  Kong  is  said  to  be  rapidly  per- 
meated by  a  fungus;  but  evidence  as  to  the  effect  of  disintegrated 
granite  or  trap  is  really  wanting. 

"In  Brazil  the  syenite  becomes  rapidly  coated  with  a  dark  sub- 
stance and  looks  like  plumbago,  and  the  Indians  believe  this  gives 
rise  to  "^calentura'  or  fevers.  The  dark  granitoid,  or  metamorphic  trap, 
or  hornblendic  rocks  in  Mysore  are  also  said  to  cause  periodic  fevers; 
and    iron   hornblende,   especially,   was   confirmed  by   Dr.    Heyne,    of 


*  Chapter  iv,  p.   130. 

'"  Practical   nvgicnc    fith  ed.,  vol.  i,  p.  359. 


196  TEXT-BOOK  OF  HYGIENE. 

Madras,  to  be  dangerous  in  this  respect.  But  the  observations  of 
Eichter  on  similar  rocks  in  Saxony,  and  the  fact  that  stations  on  the 
lower  spurs  of  the  Himalayas  on  such  rocks  are  quite  healthy,  negative 
He}Tie's  opinion. 

"  2.  The  Clay  Slate. — These  rocks  precisely  resemble  the  granite 
and  granitoid  formations  in  their  effects  on  health.  They  have  usu- 
ally much  slope,  are  very  impermeable,  vegetation  is  scanty,  and 
nothing  is  added  to  air  or  drinking-water. 

"They  are  consequently  healthy.  Water,  however,  is  often  scarce, 
and  as  to  the  granite  districts,  there  are  swollen  brooks  during  rain, 
and  dry  water-courses  at  other  times,  swelling  rapidly  after  rains. 

"  3.  The  Limestone  and  Magnesium  Limestone  Rocks. — These  so 
far  resemble  the  former  that  there  is  a  good  deal  of  slope  and  rapid 
passing  off  of  water.  Marshes,  however,  are  more  common,  and  may 
exist  at  great  heights.  In  that  case,  the  marsh  is  probably  fed  with 
water  from  some  of  the  large  cavities  which  in  the  course  of  ages 
become  hollowed  out  in  the  limestone  rocks  by  the  carbonic  acid  in  the 
rain,  and  form  reservoirs  of  water. 

"The  drinking-water  is  hard,  sparkling,  and  clear.  Of  the 
various  kinds  of  limestone,  the  hard  oolite  is  best  and  magnesium  is 
worst;  and  it  is  desirable  not  to  put  stations  on  magnesium  limestone 
if  it  can  be  avoided. 

"  4.  The  Chalk. — The  chalk,  when  mixed  with  clay,  and  perme- 
able, forms  a  very  healthy  soil.  The  air  is  pure,  and  the  water, 
though  charged  with  calcium  carbonate,  is  clear,  sparkling,  and 
pleasant.  Goitre  is  not  near'y  so  common,  nor  apparently  calculus, 
as  in  the  limestone  districts. 

"If  the  chalk  be  marly,  it  becomes  impermeable,  and  is  then 
often  damp  and  cold.  The  lower  parts  of  the  chalk,  which  are 
underlaid  by  gault  clay,  and  which  also  receive  the  drainage  of  the 
parts  above,  are  often  very  malarious;  and  in  America  some  of  the 
most  marshy  districts  are  in  the  chalk. 

"5.  The  Sandstones. — The  permeable  sandstones  are  very  healthy ; 
both  soil  and  air  are  dry;  the  drinking-water  is,  however,  sometimes 
impure.  If  the  sand  be  mixed  with  much  clay,  or  if  clay  underlies 
a  shallow  sand-rock,  the  site  is  sometimes  damp.    • 

"The  hard  millstone-grit  formations  are  very  healthy,  and  their 
conditions  resemble  those  of  granite. 

"  6.  Gravels  of  any  depth  are  always  healthy,  except  when  they 
are  much  below  the  general  surface,  and  water  rises  through  them. 
Gravel  hillocks  are  the  healthiest  of  all  sites,  and  the  water,  which 


CHARACTER  OF  THE  SOIL.  197 

often  flows  out  in  springs  near  the  base,  being  held  up  by  the  under- 
lying clay,  is  very  pure. 

"  7.  Sands. — There  are  both  healthy  and  unhealthy  sands.  The 
healthy  are  the  pure  sands,  which  contain  no  organic  matter,  and  are 
of  considerable  depth.  The  air  is  pure,  and  so  is  often  the  drinking- 
water.  Sometimes  the  drinking-water  contains  enough  iron  to  be- 
come hard,  and  even  chalybeate.  The  unhealthy  sands  are  those 
which,  like  the  subsoil  of  the  Landes,  in  southwest  France,  are  com- 
posed of  silicious  particles  (and  some  iron)  he'd  together  by  a  vege- 
table sediment. 

"In  other  cases  sand  is  unhealthy  from  underlying  clay  or 
laterite  near  the  surface,  or  from  being  so  placed  that  water  rises 
through  its  permeable  soil  from  higher  levels.  Water  may  then  be 
found  within  3  or  4  feet  of  the  surface;  and  in  this  case  the  sand 
is  imhealthy  and  often  malarious.  Impurities  are  retained  in  it  and 
effluvia  traverse  it. 

"In  a  third  class  of  cases  the  sands  are  unhealthy  because  they 
contain  soluble  mineral  matter.  Many  sands  (as,  for  example,  in 
the  Punjab)  contain  magnesium  carbonate  and  lime-salts,  as  well  as 
salts  of  the  alkalies.  The  drinking-water  may  thus  contain  large 
quantities  of  sodium  chloride,  sodium  carbonate,  and  even  lime  and 
magnesian  salts  and  iron.  Without  examination  of  the  water  it  is 
impossible  to  detect  these  points. 

"8.  Clay,  Dense  Marls,  and  Alluvial  Soils  Generally. — These 
are  always  regarded  with  suspicion.  Water  neither  runs  off  nor  runs 
through;  the  air  is  moist;  marshes  are  common;  the  composition  of 
the  water  varies,  biit  it  is  often  impure  with  lime  and  soda  salts.  In 
alluvial  soils  there  are  often  alterations  of  thin  strata  of  sand,  and 
sandy,  impermeable  clay.  Much  vegetable  matter  is  often  mixed  with 
this,  and  air  and  water  are  both  impure. 

"The  deltas  of  great  rivers  present  these  alluvial  characters  in 
the  highest  degree,  and  should  not  be  chosen  for  sites.  If  they  must 
be  taken,  only  the  most  thorough  drainage  can  make  them  healthy. 
It  is  astonishing,  however,  what  good  can  be  effected  by  the  drain- 
age of  even  a  small  area,  quite  insufficient  to  affect  the  general  atmos- 
phere of  the  place;  this  shows  that  it  is  the  local  dampness  and  the 
effluvia  which  are  the  most  hurtful. 

"9.  Cultivated  Soils. — Well-cultivated  soils  are  often  healthy; 
nor  at  present  has  it  been  proved  that  tlie  use  of  manure  is  hurtful. 
Irrigated  lands,  and  especially  rice-fields,  which  not  only  give  a  great 
surface  for  evaporation,  but  also  send  up  organic  matter  into  the  air. 


198  TEXT-BOOK  OF  HYGIENE. 

are  hurtful.  In  Northern  Italy,  where  there  is  a  very  perfect  sys- 
tem of  irrigation,  the  rice-grounds  are  ordered  to  be  kept  14  kilo- 
metres (8.7  miles)  from  the  chief  cities,  9  kilometres  (5.6  miles) 
from  the  lesser  cities  and  the  forts,  and  1  kilometre  (1094  yards)  from 
the  smaller  towns.  In  the  rice  countries  of  India  [and  America] 
this  point  should  not  be  overlooked.'' 

Where  a  wet,  impermeable,  or  impure  soil  must,  of  necessity, 
be  chosen  as  a  building-site,  it  should  be  thoroughly  drained.  The 
minimum  depth  at  which  drains  are  laid  should  be  not  less  than  ly, 
metres  below  the  floor  of  the  cellar  or  basement.  Such  a  soil  should 
be  covered  with  a  thick,  impervious  layer  of  asphaltum  or  similar 
cement  under  the  house,  in  order  to  prevent  the  aspiration  of  the  pol- 
luted ground-air  into  the  building. 

It  is  a  frequent  custom  in  cities  to  fill  in  irregularities  of  the 
building-site  with  street-sweepings  and  garbage,  which  always  con- 
tain large  quantities  of  decomposing  organic  matters.  This  is  a 
gross  violation  of  the  plainest  principles  of  hygiene.  It  is  almost 
equally  reprehensil)le  to  use  such  decaying  or  putrefying  organic  mate- 
rial for  the  purpose  of  grading  streets  or  sidewalks  in  cities  and 
to-uTis."  It  should  be  the  constant  endeavor  of  all  sanitary  authorities 
to  prevent  pollution  of  the  soil  as  much  as  possible  in  villages, 
towns,  and  cities. 

Where  houses  are  built  on  the  declivity  of  a  hill,  the  upper  Avail 
should  not  be  built  directly  against  the  ground,  as  it  would  tend  to 
keep  the  wall  damp.  A  vacant  space  should  be  left  between  the  wall 
and  the  ground  to  permit  free  access  of  air  and  light. 

In  addition  to,  or  in  default  of,  drainage,  the  dryness  of  soil 
can  be  promoted  by  rapidly-growing  plants,  which  absorb  water  from 
the  soil  and  give  it  out  to  the  air.  The  sunflower  and  the  eucalyptus 
tree  are  the  most  available  for  this  purpose. 

III.    THE  MATERIAL  OF  WHICH  THE  HOUSE  IS  BUILT. 

The  nature  of  the  most  appropriate  building  material  depends 
upon  so  many  collateral  circumstances  that  definite  rules  cannot  be 


*  During  the  very  fatal  epidemic  of  yellow  fever  in  New  Orleans,  in  1878, 
it  was  ascertained  that  a  contractor  for  street-work  used  the  garbage  and 
street-scrapings  to  grade  the  bed  of  the  streets.  Even  though  in  this  case  it 
may  not  have  intensified  the  epidemic  in  these  localities,  the  practice  is  so 
contrary  to  the  simplest  sanitary  laws  that  it  should  nowhere  be  tolerated. 
The  author  is  aware,  however,  that  the  "made-ground"  of  nearlj'  every  city 
in  this  country  is  composed  largely  of  just  such  material.  All  sanitarians 
should  protest  against  a  continuance  of  this  pernicious  practice. 


MATERIAL  OF  WHICH  THE  HOUSE  IS  BUILT.  199 

laid  down.  As  a  general  rule,  moderately  hard  burned  brick  is  the 
most  serviceable  and  available  material.  It  is  easily  permeable  by  the 
air,  and  so  permits  natural  ventilation  through  the  walls,  unless  this  is 
prevented  by  other  means.  It  does  not  absorb  and  hold  water  readily ; 
hence,  damp  walls  are  infrequent  if  brick  is  used.  It  is  probably,  of 
all  building  material,  the  most  durable.  On  account  of  its  porosity 
a  brick  wall  is  a  poor  conductor  of  heat.  It  therefore  prevents  the 
rapid  cooling  of  a  room  in  cold  weather,  and  likewise  retards  the 
heating  of  the  inside  air  from  without  in  summer.  Another  very 
great  advantage  is  its  resistance  to  a  very  high  degree  of  heat,  brick 
being  probably  more  nearly  fire-proof  than  any  other  building  mate- 
rial. 

In  hot  climates  light  wooden  buildings  are  advantageous  because 
they  cool  off  very  rapidly  after  the  sun  has  disappeared.  On  account 
of  the  numerous  Joints  and  fissures  in  a  frame  building,  natural  ven- 
tilation goes  on  very  readily  and  to   a  considerable  extent. 

Next  to  brick,  granite,  marble,  and  sandstone  are  the  most  ser- 
viceable building  materials.  Very  porous  sandstone  is,  however,  not 
very  durable  in  cold  climates,  as  the  stone  absorbs  large  quantities  of 
water,  which,  in  consequence  of  the  expansion  accompanying  the  act 
of  freezing,  produces  a  gradual  but  progressive  disintegration.  Ee- 
cently,  concrete  has  been  successfully  employed  as  a  building  material. 

The  application  of  paint  to  the  walls,  either  within  or  without, 
almost  completely  checks  the  transpiration  of  air  through  the  walls, 
thus  limiting  natural  ventilation.  Calcimining,  on  the  other  hand, 
offers  very  little  obstruction  to  the  passage  of  air.  Wall-paper  is 
about  midway  between  paint  and  lime-coating  in  its  obstructive  effect 
on  atmospheric  transpiration. 

ISTewly-built  houses  should  not  be  occupied  until  the  walls  have 
become  dry.  Moisture  in  the  walls  is  probably  a  not  infrequent  source 
of  ill  health;  it  offers  favorable  conditions  for  the  development  of 
fungi  (possibly  disease-germs),  and  by  filling  up  the  pores  of  the 
material  of  which  the  walls  are  composed,  prevents  the  free  transpira- 
tion of  air  through  them. 

Moisture  of  the  walls  is  sometimes  due  to  the  ascent  of  the  water 
from  the  soil  by  capillary  attraction.  This  can  be  prevented  by  inter- 
posing an  impervious  layer  of  slate  in  the  foundation-wall. 

Where  the  moisture  is  due  to  the  rain  beating  against  the  out- 
side walls,  and  thus  saturating  them  if  composed  of  porous  materials. 
a  thorough  external  coating  of  impervious  paint  will  prove  a  good 
remedy. 


200  TEXT-BOOK  OF  HYGIENE. 


IV.    INTERIOR  ARRANGEMENTS. 

A.  Size  of  Eooms,  and  Ventilating  and  Heating  Arrangements. — 

The  rooms  in  dwelling-houses  should  never  be  under  V- / ^  metres  in 
height  from  floor  to  ceiling.  In  sleeping-rooms  the  initial  air-space 
should  never  be  less  than  35  cubic  metres  for  adults,  and  25  cubic 
metres  for  children  under  10  years  of  age.  Provision  must  be  made 
for  changing  this  air  sufficiently  often  to  maintain  it  at  its  standard 
of  purity;  i.e.,  less  than  7  parts  of  carbon  dioxide  per  10,000.  The 
details  for  accomplishing  this  will  vary  with  the  architect's  designs, 
the  material  of  which  the  house  is  constructed,  the  climate,  and  the 
season.  The  principles  laid  down  in  the  section  on  ventilation 
(Chapter  1)  should  be  adhered  to.  In  cold  weather  the  air  should 
be  warmed,  either  before  its  entrance  into  the  room  or  afterward,  by 
stove  or  fire-place.  Gallon's  jacketed  stove,  or  fire-place,  seems  to 
answer  this  purpose  admirably.  The  details  of  the  heating  apparatus 
must  be  left  to  individual  taste,  or  other  circumstances.  It  may  be 
noted,  however,  in  passing,  that  the  prevailing  method  of  heating 
houses  by  means  of  hot  air  is  objectionable  for  various  reasons: 
partly,  because  the  air  is  usually  too  dry  to  be  comfortable  to  the 
respiratory  organs;  partly,  because  organic  matter  is  frequently  pres- 
ent in  large  proportions,  and  gives  the  air  an  offensive  odor  when  the 
degree  of  heat  is  high  enough  to  scorch  the  organic  matter.  Both  these 
objections  are,  however,  removable;  the  first  by  keeping  a  vessel  of 
water  constantly  in  the  furnace,  so  that  the  hot  air  can  take  up  a  suffi- 
cient proportion  of  vapor  in  passing  tlirough,  and,  the  second,  by 
having  the  furnace  made  large  enough  so  that  the  temperature  need 
never  be  raised  to  a  very  high  degree.  Heating  by  hot  water  or 
steam  is  preferable  to  the  hot-air  furnace.  Both  of  these  methods 
are,  however,  more   expensive  to   install. 

Where  special  ventilating  arrangements  are  necessary,  air-inlets 
may  be  inserted  at  appropriate  points  in  the  walls  of  the  room,  fac- 
ing toward  the  air.  A  simple  arrangement  is  that  known  as  the 
Bury  Ventilator,  shown  in  Figs.  14  and  15.  It  consists  of  a  wooden 
block  interposed  'between  the  bottom  of  the  lower  window-sash  and 
the  window-frame.  The  air  passes  into  the  room  through  the  open- 
ings in  the  block,  as  shown  in  the  illustration.  The  separation  of  the 
upper  and  lower  sashes,  when  the  ventilator  is  in  place,  also  adds 
to  the  efficiency  of  the  ventilation,  as  the  air  passes  in  through  the 
space  so  formed. 


INTEEIOR  ARRANGEMENTS. 


201 


A  cheaper  ventilator  can  be  made  by  simply  tacking  a  strip 
of  canvas,  binders'  board,  or  manilla  jiaper,  20  to  25  centimetres  wide, 
across  the  lower  portion  of  the  window-frame,  and  then  raising  the 


Fie.  14. 


Fis;.   15. 


Fig.  14. — a,  a,  Sash.  6,  &,  Window-jambs,  c,  c,  Window-sill.  This 
cut  represents  the  view  from  within  the  Bury  Ventilator,  in  operation. 
It  is  broken  away  at  one  end  to  show  the  sash  raised  above  the  outer 
holes  to  admit  the  air. 

Fig.  15. — a,  a,  Sash.  This  cut  represents  the  view  from  without 
the  Bury  Ventilator,  in  operation.  The  sasJi  is  broken  away  to  show 
the  ventilator  behind,  with  the  fresh  air  passing  in. 


sash  10  to  15  centimetres.  The  air  will  pass  in  under  the  lower  and 
between  the  lower  and  upper  sashes  and  pass  upward  toward  the  ceil- 
ing find  thou  grndnany  difl'upe  itself  through  the  room.     In  summer 


202 


TEXT-BOOK  OF  HYGIENE. 


a  counter-opening  may  be  obtained  for  the  escape  of  foul  air  by  low- 
ering the  upper  sash,  while  in  winter  a  stove  or  fire-place  will  furnish 
a  good  exit. 


p^ 


O 


O 


be 


Fig.  16  shows  the  probable  course  of  the  air-currents  in  a  room 
ventilated  by  means  of  a  fresh-air  inlet  near  the  ceiling  and  an  open 
fire-place.  A  is  the  inlet ;  C,  the  fire-place ;  G,  the  floor ;  F,  ceiling ; 
E  E,  flues. 


INTERIOR  ARRANGEMENTS.  203 

B.  Internal  Wall-coating. — A  point  of  considerable  importance 
in  the  outfitting  of  dwelling-liouses  is  the  material  used  for  coating 
or  decorating  the  inside  of  the  walls.  Green  paint  ar.d  green-colored 
wall-papers  should  be  rejected.  The  reason  for  avoiding  this  color 
is  the  following:  Bright-green  pigments  and  dyes  are  largely  com- 
posed of  some  compound  of  arsenic,  which  becomes  detached  from  the 
wall  or  paper  when  dry  and,  being  inhaled,  produces  a  train  of 
symptoms  which  have  been  recognized  as  chronic  arsenical  poisoning. 
Many  cases  have  been  reported  in  which  serious  and  even  fatal  poison- 
ing has  been  produced  in  this  way.'^  It  would  be  advisable,  therefore, 
to  discard  all  bright-green  tints  in  paints  and  ornamental  paper- 
hangings. 

C.  Lighting. — Provision  should  be  made  in  all  dwelling-houses 
for  an  abundant  supply  of  sunlight.  Every  room  should  have  at  least 
one  window  opening  directly  to  the  sun.  It  is  not  sufficient  to  give  an 
ample  window-space,  which  should  be  in  the  proportion  of  one  to  five 
or  six  of  floor-space,  but  the  immediate  surroundings  of  the  house 
must  be  taken  into  account.  Thus,  close  proximity  of  other  buildings, 
or  of  trees,  may  prevent  sufficient  light  entering  a  room,  although 
the  window-space  may  be  in  excess  of  that  required  under  ordinary 
circumstances. 

Some  form  of  artificial  light  will  also  be  needed  in  all  dwell- 
ings. Certain  dangers  are  necessary  accompaniments  of  all  avail- 
able methods  of  artificial  illumination.  The  danger  from  fire  is,  of 
course,  the  most  serious.  This  danger  is  probably  least  where  candles 
are  used,  and  greatest  where  the  more  volatile  oils  (kerosene,  gasolene) 
are  employed.  The  use  of  candles  results  in  pollution  of  the  air  by 
carbon  dioxide  and  other  products  of  combustion  to  a  greater  degree 
than  when  other  illuminating  agents  are  used;  they  also  give  out 
a  larger  amount  of  heat  in  proportion  to  their  power  of  illumina- 
tion. Kerosene  gives  a  good  light  when  burned  in  a  proper  lamp, 
and  is  cheap,  but  the  dangers  from  explosion  and  fire  are  consider- 
able. The  danger  from  explosion  can  be  greatly  reduced  by  always 
keeping  the  lamp  filled  nearly  to  the  top,  and  never  filling  it  near  a 
light  or  fire.  The  danger  of  explosion  is  Increased  when  the  chimney 
of  the  lamp  is  broken,  as  then  the  temperature  of  the  metal  collar, 
by  which  the  burner  is  fastened  to  the  lamp,  is  rapidly  raised®  and 
the  oil  vaporized.     If,  at  the  same  time,  the  lamp  is  only  partially 


'Arsenic  in  Certain  Green  Colors,  F.  W.  Draper.     Third  Annual  Report 
Mass.  State  Board  of  Health,  1872,  pp.  18-57. 

»H.  B.  Baker,  in  Report  Mich.  State  Board  of  Health,  1876,  p.  48. 


204  TEXT-BOOK  OF  HYGIENE. 

filled  with  oil,  the  space  above  it  is  occupied  by  an  explosive  mixture 
of  air  and  the  vapor  of  the  oil.  If  this  is  heated  to  a  sufficient  degree 
an  explosion  will  take  place. ^ 

The  use  of  coal-gas  is  probably  attended  by  less  danger  than  the 
lighter  oils,  but  by  more  than  other  means  of  illumination.  In  addi- 
tion to  the  dangers  from  fire  and  explosions,  which  are  inevitable  ac- 
companiments of  defects  in  the  fixtures,  the  escaping  gas  is  itself 
exceedingly  poisonous  from  the  large  amount  of  carbon  monoxide  it 
contains.  It  is,  in  fact,  a  very  frequent  occurrence  in  large  cities  that 
persons  are  killed  by  the  inhalation  of  gas  which  has  escaped  from 
the  fixtures  or  was  allowed  to  escape  from  the  burner  through  igno- 
rance. That  variety  of  illuminating  gas  Imown  as  "water-gas"  is  more 
dangerous  to  inhale  than  coal-gas  owing  to  the  larger  proportion  of 
carbon  monoxide  contained  in  it.  Eecent  experiments  by  T.  A.  Maass 
indicate  that  the  toxic  action  of  illuminating  gas  is  due  in  part  to 
some  factor  aside  from  the  carbonic  oxide,  as  it  is  so  much  more  toxic 
than  CO  alone.  The  "natural  gas"  used  as  a  fuel  and  illuminant  in 
some  places  in  the  United  States  is  especially  dangerous  from  the 
total  absence  of  odor.  The  gas  may  escape  in  large  quantity  and  fail 
to  give  notice  of  its  presence  except  by  an  explosion,  if  ignited,  or 
by  producing  asphyxia  in  those  who  incautiously  venture  into  the 
air  permeated  by  it.  The  slight  but  continuous  escape  of  gas  from 
defective  or  leaky  fixtures  may  produce  a  grave  form  of  anemia. 
Chronic  CO  poisoning  is  probably  of  more  frequent  occurrence  in 
cities  than  is  generally  suspected. 

The  electric  light  (Edison's  incandescent  system)  is  probably 
open  to  less  objection  on  the  score  of  danger  than  any  other  of  the 
illuminating  systems  mentioned.  There  is  no  trustworthy  evidence 
that  the  electric  light  has  any  unfavorable  influence  on  the  vision, 
although  Eegnault  supposed  it  would  have  a  bad  effect  upon  the 
ocular  humors  on  account  of  the  large  proportion  of  the  violet  and 
ultra-violet  rays  it  contained.  In  order  to  remove  this  objection 
Bouchardat  advised  the  wearing  of  yellow  glasses  by  those  compelled 
to  use  this  light  for  close  work.  The  advantages  of  the  incandescent 
light,  besides  the  brilliant  white  light  it  gives,  are  that  it  is  steady 
and  does  not  produce  any  heat,  nor  does  it  pollute  the  air  with  car- 
bon dioxide  and  other  products  of  combustion.  Professor  von  Petten- 
kofer  has  shown  experimentally  that  the  pollution  of  the  air  by 
'the  products  of  combustion  is  very  much  greater  when  gas  is  used 

"See  an  instructive  paper  by  Prof.  E..  C.  Kedzie,  in  Report  Mich.  State 
Board  of  Health  for  1877,  p.  71  et  seq. 


HOUSE-DRAINAGE.  205 

than  where  the  electric  light  is  employed.  The  electric  arc-lights  are 
extremely  dangerous  on  account  of  the  high  potential  maintained  in 
the  wires,  and  the  difficulty  of  thoroughly  insulating  the  latter.  Many 
deaths  have  occurred  from  this  source,  and  unless  a  method  is  dis- 
covered and  adopted  by  which  the  voltage  of  the  arc-light  current  can 
be  greatly  diminished  without  decreasing  the  efficiency  of  the  light, 
this  method  of  lighting  must  soon  be  given  up  in  cities,  owing  to  its 
danger,  not  only  to  those  directly  brought  in  contact  with  the  conduc- 
tors, but  to  others  who  may  indirectly  get  in  the  way  of  the  errant 
current. 

In  writing,  sewing,  reading,  or  other  work  requiring  a  constant 
use  of  accurate  vision,  the  light,  whether  natural  or  artificial,  should 
fall  upon  the  object  from  above  and  on  the  left  side.  Hence,  windows 
and  burners  should  be  at  least  the  height  of  the  shoulder  and  to  the 
left  of  the  person  using  the  light. 

Increased  ventilation  facilities  must  be  provided  where  artificial 
light  (except  the  electric  light)  is  used  to  any  extent.  It  has  been 
•calculated  that  for  every  lighted  gas-burner  12  to  15  cubic  metres  of 
fresh  air  per  hour  must  be  furnished  in  addition  to  the  amount  or- 
dinarily required  in  order  to  maintain  the  air  of  the  room  at  the 
standard  of  purity. 

V.    WATER=SUPPLY. 

The  water-supply  of  a  dwelling-house  should  be  plentiful  for 
all  requirements,  and  its  distribution  should  be  so  arranged  that  the 
supply  for  every  room  is  easily  accessible.  Where  practicable,  water- 
taps  should  be  placed  on  every  floor,  both  for  convenience  and  for 
greater  safety  in  case  of  fire.  It  is  also  a  result  of  observation  that 
personal  habits  of  cleanliness  increase  in  a  direct  ratio  with  the  ease 
of  obtaining  the  cleansing  agent.  The  inmates  of  a  house  where 
water  is  obtainable  with  little  exertion  are  much  more  likely  to  be 
cleanly  in  habits  than  where  the  water-supply  is  deficient  or  not 
readily  procured. 

VI.    HOUSE=DRAINAGE. 

Provision  must  be  made  for  the  rapid  and  thorough  removal  of 
waste-water  and  excrementitious  substances  from  the  house.  This  is 
most  easily  and  completely  accomplished  by  well-constructed  water- 
closets  and  sinks.  Water-closets  should,  however,  not  be  tolerated  in 
any  room  occupied  as  a  living-  or  bed-  room.     It  would  doubtless  be 


206  TEXT-BOOK  OF  HYGIENE. 

very  much  more  in  accordance  with  sanitary  requirements  to  have  all 
permanent  water-fixtures,  water-closets,  and  bathing  arrangements 
placed  in  an  annex  to  the  dwelling  proper.  In  this  way  the  most 
serious  danger  from  water-closets  and  all  arrangements  having  a 
connection  with  a  cess-pool  or  common  sewer — permeation  of  the 
house  by  sewer-air — could  be  avoided. 

Water-closets,  hovrever,  presuppose  an  abundant  supply  of  water. 
Unless  this  can  be  obtained  and  rendered  available  for  flushing  the 
closets,  soil-pipe,  and  house-drain,  the  dry-earth  or  pail  system  should 
be  adopted.  Privies  should  not  be  countenanced.  Experience  in  sev- 
eral large  cities  of  Europe  has  demonstrated^*'  that  the  pail  system 
can  be  adopted  with  advantage  and  satisfactorily  managed  even  in 
large  communities. 

As  house-drainage  may  be  considered  the  first  and  most  import- 
ant link  in  a  good  sewerage  system,  a  brief  description  will  be  here 
given  of  the  details  of  the  drainage  arrangements  of  a  dwelling- 
house.  The  rapid  and  complete  removal  of  all  fecal  and  urinary 
discharges,  lavatory-  and  bath-  wastes,  and  kitchen-slops  must  be 
provided  for.  For  these  purposes  are  needed,  first,  water-closets  and 
urinals,  wash-basins  and  bath-tubs,  and  kitchen-  or  slop-  sinks; 
second,  a  perpendicular  pipe,  with  which  the  foregoing  are  connected, 
termed  the  soil-pipe;  and  tliird,  a  horizontal  pipe,  or  house-drain, 
connecting  with  the  common  cess-pool  or  sewer. 

A.  Water-closets. — There  are  five  classes  of  water-closets  in  gen- 
eral use.  They  are  the  pan-,  valve-,  plunger-,  hopper-,  and  washout- 
closets. 

Pan-closets  are  those  found  in  most  old  houses  containing  water- 
closet  fixtures.  Just  under  the  bowl  of  the  closet  is  a  shallow  pan  con- 
taining a  little  water,  in  which  the  dejections  are  received.  On  rais- 
ing the  handle  of  the  closet,  the  pan  is  tilted  and  the  water  at  the 
same  time  is  turned  on,  which  washes  out  the  excrement  and  sends  it 
into  or  through  the  trap  between  the  closet  and  the  soil-pipe.  It  will 
be  readily  understood  that  the  space  required  for  the  movement  of 
the  pan — the  "container,"  as  it  is  termed — is  rarely  thoroughly 
cleansed  by  the  passage  of  water  through  it.  Fecal  matter,  paper,  etc., 
gradually  accumulate  in  the  comers  of  the  container,  and,  as  a  con- 
sequence, pan-closets  are  always,  after  a  brief  period  of  use,  foul. 
There  are  other  defects  in  the  construction  of  the  pan-closet  which 
render   it   untrustworthy,   but    the    one   especially    pointed    out — the 


See  Chapter  v,  p.   139. 


HOUSE-DRAINAGE. 


207 


impossibility  of  keeping  it  clean — :s  enough  to  absolutely  condemn 
its  use,  from  a  sanitary  point  of  view.  It  is  decidedly  the  worst  form 
of  closet  that  can  be  used. 

Valve-closets  are  merely  modifications  of  the  pan-closet.  The 
bottom  of  the  bowl  is  closed  by  a  flat  valve,  which  is  held  in  its  place 
by  a  weight.  By  moving  a  lever  the  valve  is  turned  down,  allowing 
the  excreta  to  drop  into  the  container.  The  only  differences  between 
the  pan-  and  valve-closets  are  that  in  the  latter  a  flat  valve  is  substi- 
tuted for  the  pan  of  the  former,  and  that  this  allows  the  container 


Fig.  17. — The    "Dececo"    Closet    (New   Form) 


to  be  made  smaller.  Otherwise  there  are  no  advantages  in  the  valve- 
closet.  Considered  from  a  sanitary  standpoint,  the  valve-closet  is  no 
worse  than  the  pan-closet,  and  but  very  little,  if  any,  better. 

The  third  variety,  or  plunger-closet,  has  several  marked  advan- 
tages over  the  two  just  described.  -The  characteristic  feature  of  the 
closets  of  this  class  is  that  the  outlet,  which  is  generally  on  one  side 
of  the  bowl,  is  closed  by  a  plunger.  This  bowl  is  always  from  one- 
third  to  one-half  full  of  water,  into  which  the  excreta  fall.  On  rais- 
ing the  plunger,  the  entire  contents  of  the  bowl  are  rapidly  swept  out 
of  the  apparatus  into  the  soil-pipe,  the  bowl  thoroughly  washed  out 


208 


TEXT-BOOK  OF  HYGIENE. 


Fiff.  18.— The  "A.  G.  M."  Closet. 


HOUSE-DRAINAGE. 


209 


by  a  sudden  discharge  of  water,  and,  on  closing  the  outlet  with  the 
plunger,  the  bowl  is  again  partly  filled  with  water.  An  overflow 
attachment  prevents  accumulation  of  too  large  a  quantity  of  water  in 
the  bowl.  This  overflow,  however,  sometimes  becomes  very  foul  and 
objectionable.  The  Jennings,  Demarest,  and  Hygeia  are  types  of  this 
class.  The  principal  objection  is  that  the  plunger  sometimes  fails  to 
properly  close  the  outlet,  allowing  the  water  to  drain  out  of  the 
bowl,  and  thus  destroying  one  of  its  principal  advantages.  The  me- 
chanism is  also  somewhat  complicated  and  likely  to  get  out  of  order. 


Fig.  19.— Sectional  View  of  "A.  G.  M."  Closet. 


The  hopper-closet  consists  of  a  deep  earthenware  or  enameled 
iron  bowl,  with  a  water  seal  trap  directly  underneath.  The  excreta 
are  received  directly  inio  the  proximal  end  of  the  trap,  and  when 
the  water  is  turned  on  the  sides  of  the  bowl  are  washed  clean  and 
everything  in  the  bowl  and  trap  swept  directly  into  the  soil-pipe. 
There  is  no  complicated  mechanism  to  get  out  of  order,  the  trap  is 
always  in  sight,  and  the  entire  apparatus  can  always  be  kept  clean 
and  inoffensive,  as  there  are  no  hidden  corners  or  angles  for  filth 
to  lodge.  This  form  of  closet  is,  all  things  considered,  one  of  the 
best  for  general  use. 

14 


210  TEXT-BOOK  OF  HYGIENE. 

The  "wash-out"  closets  are  of  various  shapes,  some  having  the 
trap  in  the  bowl  itself,  others  having  a  double  water-trap.  They  are 
generally  simple  in  construction,  and  not  likely  to  get  out  of  order. 
They  do  not  present  any  decided  advantages  over  the  simple  hopper, 
although  at  the  present  time  they  are  more  used  than  any  other  form 
of  closet.  Of  the  recent  improvements  in  this  form  of  closet  may 
be  mentioned  the  "A.  G.  M.,""  shown  in  view  with  intern  in  Fig.  18, 
and  in  section  in  Fig.  19,  and  the  "Dececo,"  Fig.  17,  invented  by  Col. 
George  E.  Waring,  In  the  latter  the  automatic  siphon  principle,  so 
ingeniously  used  by  Eogers  Field  in  the  construction  of  the  automatic 
flush-tank,  is  applied  to  the  scouring  of  a  water-closet.  Practical 
experience  for  a  number  of  years  has  demonstrated  the  great  useful- 
ness of  this  closet.  If  the  delivery  of  water  from  the  flushing-cistern 
is  properly  regulated,  at  first  rapid  to  thoroughly  wash  out  the  closet 
and  connections,  and  then  slow  to  re-establish  the  proper  depth  of 
seal  in  the  trap,  the  closet  should  be  thoroughly  satisfactory  in  its 
workings. 

Water-closets  should  not  be  inclosed  in  wooden  casings,  as  is  al- 
most universally  done.  Everything  connected  with  the  closet,  soil-, 
and  drain-  pipes,  water-supply,  and  all  joints  and  fixtures  should  be 
exposed  to  view  so  that  the  defects  can  be  immediately  seen  and  easily 
corrected.  By  laying  the  floor  and  back  of  the  closet  in  tiles  or  cement, 
such  an  arrangement  can  even  be  made  ornamental,  as  suggested  by 
Waring,^"  who  says  that  a  closet  "made  of  white  earthenware,  and 
standing  as  a  white  vase  in  a  floor  of  white  tiles,'  the  back  and  side 
walls  being  similarly  tiled,  there  being  no  mechanism  of  any  kind 
under  the  seat,  is  not  only  most  cleanly  and  attractive  in  appearance, 
but  entirely  open  to  inspection  and  ventilation.  The  seat  for  this 
closet  is  simply  a  well-finished  hard-wood  board,  resting  on  cleats  a 
little  higher  than  the  top  of  the  vase,  and  hinged  so  that  it  may  be 
conveniently  turned  up,  exposing  the  closet  for  thorough  cleansing,  or 
for  use  as  a  urinal  or  slop-hopper." 

Where  the  arrangement  here  described  is  adopted,  extra  urinals 
are  unnecessary  and  undesirable.  Where  they  are  used  they  should 
be  constantly  and  freely  flushed  with  water,  otherwise  they  become 
very  offensive.  The  floor  of  the  urinal  should  be  either  of  tiling,  slate, 
or  enameled  iron. 


^^Manufactured  by  the  ilyers   Sanitary  Dapot,   New  York. 
"  Sanitary   Condition  of  New  York   City,   Scribner's  Monthly,  vol.  xxii, 
No.  2,  June,   1881. 


HOUSE-DRAINAGE. 


211 


B.  Water-supply  for  Closets. — The  water-supply  for  flushing 
water-closets  should  not  be  taken  directly  from  the  common  house- 
water  supply,  but  each  closet  should  have  an  independent  cistern  large 
enough  to  hold  a  sufficient  quantity  of  water  for  a  thorough  flushing 
(30  to  30  litres)  every  time  the  closet  is  used.  The  objections  to 
connecting  the  water-closet  directly  with  the  common  house-supply 
are,  that  there  is  often  too  little  head  of  water  to  properly  flush  the 


Tier.  20. — Flushinor  Cistern  for  Water-closets. 


basin;  and,  secondly,  if  the  water  be  drawn  from  a  fixture  in  the 
lower  part  of  the  house,  while  the  valve  of  a  water-closet  in  an  upper 
floor  is  open  at  the  same  time,  the  water  will  not  flow  in  the  latter 
(unless  the  supply-pipe  is  very  large),  but  the  foul  air  from  the  closet 
will  enter  the  water-pipe,  and  may  thus  produce  dangerous  fouling 
of  the  drinking-water.  Plence,  separate  cisterns  for  each  water-closet 
should  always  be  insisted  upon. 

The  arrangement  of  these  cisterns  is  often  difficult  to  compre- 
hend. Fig.  20  shows  the  interior  arrangement  of  one  form.  The 
hall-shaped  float,  a,  cuts  off  the  s^ipply  when  the  tank  is  full,  while 
opening  the  valve,  h,  by  means  of  the  crank,  c,  discliargos  the  water. 
The  rounded  annex,  d,  contains  water  enough  to  partly  fill  the  closet- 


212 


TEXT-BOOK  OF  HYGIENE. 


bowl  and  trap  after  the  contents  have  been  washed  out  by  the  rapid 
flush. 

C.  Traps. — Every  water-closet,  urinal,  wash-basin,  bath-tub,  and 
kitchen-sink  should  have  an  appropriate  trap  between  the  fixture  and 
the  soil-pipe.  The  trap  should  be  placed  as  near  the  fixture  as  prac- 
ticable, as  pointed  out  above;  in  the  best  forms  of  water-closet  the 
bottom  of  the  closet  itself  forms  part  of  the  trap. 

Traps  differ  in  shape  and  mechanism.  The  simplest  and  usually 
efficient  is  the  ordinary  S-trap  (Fig.  21).  This  trap  is  of  uniform 
diameter  throughout,  and  has  no  angles  for  the  lodgment  of  filth. 
A  free  flush  of  water  cleanses  it  perfectly,  and  it  rarely  fails  to 
furnish  a  sufficient  obstruction  to  the  passage  of  sewer-air  from  the 
soil-pipe,  unless  the  water  has  evaporated  or  been  forced  out  under 
a  back-pressure  of  air  in  the  soil-pipe,  or  been  siphoned  out,  and  thus 
the  seal  broken. 


Fig.  21.— S-Trap. 


The  D-trap  and  bottle-trap  are  objectionable  on  account  of  the 
great  liability  of  becoming  fouled  by  filth  lodging  in  the  corners, 
while  in  the  mechanical  traps,  like  Bowers'  ball-valve  trap,  Cudell's 
trap,  and  others  of  this  class,  there  is  always  danger  of  insufficient 
seal  by  filth  adhering  to  the  valve,  and  thus  preventing  its  exact 
closure. 

Most  of  the  traps  now  furnished  by  the  dealers  in  plumber's 
supplies  have  an  opening  in  the  highest  part  for  attaching  a  vent- 
pipe.  It  has  been  found  that  the  seal  in  most  traps  can  be  broken 
by  siphonage,  if  the  pressure  of  air  on  the  distal  side  (the  side 
toward  the  soil-pipe)  of  the  trap  is  diminished,  or,  on  the  other  hand, 
by  increase  of  pressure  in  the  soil-pipe  the  water  in  the  trap  may  be 
forced  back  into  the  fixture,  and  thus  sewer-air  enter  the  room.  By 
providing  for  a  free  entrance  and  exit  of  air  to  the  trap  this  break- 
ing of  the  seal  can  be  prevented.  The  ventilation  of  traps  is,  however, 
an  evil,  as  it  furnishes  an  additional  means  of  evaporation,  and  when 


HOUSE-DRAINAGE. 


213 


the  fixture  is  not  in  frequent  (daily)  use  the  seal  is  sooner  broken. 
The  elaborate  extra  system  of  ventilation  of  traps,  so  generally  insisted 
upon  by  plumbers  and  sanitary  engineers,  is  unnecessary.  If  the  soil- 
pipe  is  of  the  proper  size  and  height,  siphonage  of  traps  will  not  be 
likely  to  occur.  The  waste-pipe  connecting  the  fixture  and  the  soil- 
pipe  should  be  as  short  as  possible;  in  other  words,  all  water-closets, 
urinals,  baths,  and  lavatories  should  be  placed  as  near  the  soil-pipe 
as  practicable,  in  order  to  have  no  long  reaches  of  foul  waste-pipe 
under  floors  or  in  rooms. 


Fig.  22.  Fig.  23. 

Fig.  22. — Sectional  View  of  Vent,  with  Cap  in  Normal  Position. 

Fig.  23. — Sectional  View  of  Vent,  with  Cup  Lifted  out  of  the  Mercury 
by  the  Inflowing  Current  of  Air  Indicated  by  the  Arrows. 


Dr.  E.  S.  McClellan  has  recently  invented  a  trap  which  obviates 
many  of  the  objections  urged  against  all  previous  devices,  and  is 
intended  to  meet  the  defects  of  the  S  and  other  traps.  It  consists  of 
a  body  containing  a  light,  inverted  cup,  with  its  edges  resting  in  an 
annular  groove  containing  mercury,  which  forms  an  absolute  seal 
against  the  escape  of  sewer-air.  When  a  slight  diminution  of  pressure 
occurs  on  the  sewer  side  of  the  cup,  the  greater  external  pressure  lifts 
the  cup  out  of  the  mercury  and  permits  a  free  inflow  of  air  until  the 
wonted  equilibrium  is  re-established,  when  the  cup  drops  back  into 
the  mercury  by  gravity,  and  effectually  closes  the  trap  against  any 


214 


TEXT-BOOK  OF  HYGIENE. 


outflow.  With  this  trap  siphonage  of  the  seal  is  impossible.  Fig. 
22  shows  this  trap  with  the  cup  down,  and  Fig.  23  with  the  cup 
raised,  allowing  inflow  of  air. 

For  an  ordinary  wash-bowl  or  bath-waste  (which  should  always 
be  trapped),  the  Connolly  globe-trap,  shown  in  Figs.  24  and  25,  is 
an  excellent  fixture.  It  is  impossible,  under  ordinary  circumstances, 
to  break  the  seal  by  siphonage. 

D.  The  Soil-pipe. — The  vertical  pipe  connecting  the  water-closets 
and  other  fixtures  with  the  house-drain  is  called  the  soil-pipe.     It 


Fig.  24. — Connolly  Globe-trap. 


Fig.  25. — Globe-trap  Attached  to  Basin. 


should  be  of  iron,  securely  jointed,  of  an  equal  diameter  (usually  10 
centimetres)  throughout,  and  extend  from  the  house-drain  to  from 
l^/o  to  2  metres  above  the  highest  point  of  the  house.  The  connec- 
tions of  all  the  waste-pipes  from  water-closets,  baths,  etc.,  should  be 
at  an  acute  angle,  in  order  that  an  inflow  at  or  nearly  at  right  angles 
may  not  produce  an  obstruction  in  the  free  passage  of  air  up  and 
down  the  soil-pipe.  The  diameter  of  the  soil-pipe,  at  its  free  upper 
end,  should  not  be  narrowed ;  in  fact,  according  to  Col.  Geo.  E.  War- 
ing, the  up  draught  is  rendered  more  decided  if  the  upper  extremity 


HOUSE-DRAINAGE.  215 

of  the  soil-pipe  is  widened.^^  The  internal  surface  of  the  pipe  should 
be  smooth,  and  especial  care  should  be  taken  to  prevent  projections 
inward  at  the  joints;  otherwise,  paper  and  other  matters  will  adhere 
to  the  projections,  and  gradually  obstruct  the  pipe. 

E.  The  House-drain. — The  horizontal  or  slightly  inclined  pipe 
which  connects  the  lower  end  of  the  soil-pipe  with  the  sewer  or  cess- 
pool, the  point  of  final  discharge  from  the  house,  should  be  of  the  same 
diameter  and  material  as  the  soil-pipe.  The  joints  should  be  made 
with  equal  care,  and  the  pipe  should  be  exposed  to  view  throughout 
while  within  the  house-walls.  If  sunk  below  the  floor  of  the  cellar 
it  should  be  laid  in  a  covered  trench,  so  that  it  may  be  readily  in- 
spected. The  junction  between  the  vertical  and  horizontal  pipe 
should  not  be  at  a  right  angle,  but  the  angle  should  be  rounded.  The 
drain-pipe  should  not  be  trapped.  This  is  contrary  to  the  advice  of 
sanitary  authorities  generally,  but  the  author  thinks  it  unadvisable 
to  trap  the  drain-pipe.  There  should  be  no  obstruction  to  the  out- 
flow of  sewage  from  the  house,  and  a  trap  in  the  drain-pipe  is  of 
no  avail  against  the  passage  of  sewer-air  from  the  sewer  or  cess- 
pool into  the  soil-pipe,  if  the  pressure  of  air  in  the  former  is  increased. 
Furthermore,  if  the  passage  of  air  backward  and  forward  between  the 
sewer  and  the  external  air  at  a  sufficient  height  (above  the  roofs  of 
houses,  for  example)  is  free  and  unobstructed,  the  sewers  (or  the  cess- 
pool, as  the  case  may  be)  will  be  better  ventilated  than  if  any  obstruc- 
tion to  such  free  circulation,  in  the  form  of  a  trap,  be  placed  in  the 
drain-pipe. 

Nearly  all  sanitary  authorities  direct  that  an  opening  for  the 
admission  of  fresh  air — "fresh-air  inlet" — should  be  made  in  the 
drain-pipe,  before  its  connection  with  the  sewer  or  cesspool.  This 
is  done  with  the  view  of  having  a  constant  current  of  fresh  air  enter- 
ing near  the  base  of  the  soil-pipe  and  passing  upward  through  it. 
Theoretically,  the  current  ought  always  to  pass  in  this  direction. 
Practically,  however,  the  current  is  found,  at  times,  to  pass  the  other 
way,  and  the  foul  air  from  the  soil-pipe  may  be  discharged  into  the 
air  near  the  ground,  where  it  would  be  much  more  likely  to  do  harm 
than  when  discharged  high  up  in  the  air  beyond  the  possibility  of 
being  breathed. 


»»Am.  Architect,  p.  124,  Sept.  15,  1883. 


216  TEXT-BOOK  OF  HYGIENE. 

OFFICIAL  SUPERVISION  OF  THE  SANITARY  ARRANGEMENTS 
OF  DWELLINGS. 

In  most  towns  and  cities  the  municipal  authorities  have  pro- 
vided for  an  official  inspection  of  buildings,  to  prevent  neglect  of  pre- 
cautions against  fire  and  other  manifest  dangers  to  life.  It  is 
only  very  recently,  however,  that  the  authorities  of  some  of  the  larger 
cities  in  this  country  have  enacted  laws  to  prevent  improper  construc- 
tion of  house-drainage  works.  Although  none  of  these  laws  or  or- 
dinances cover  the  subject  completely,  yet  their  proper  enforcement 
must  result  in  great  advantage. 

Within  the  past  few  years,  following  the  example  of  Edinburgh, 
volunteer  associations  have  been  organized  in  various  cities  of  this 
country,  with  the  object  of  securing  constant  expert  inspection  and 
supervision  of  the  drainage  arrangements  of  dwellings  and  other 
necessary  sanitary  improvements. 

The  good  results  accomplished  by  the  Newport  Sanitary  Protec- 
tion Society,  the  ISTew  Orleans  Auxiliary  Sanitary  Association,  and 
other  similar  bodies  attest  the  usefulness  of  such  organizations. 

THE  INTERIOR  ARRANGEMENT  OF  THE   HOUSE. 

A  dwelling  is  neither  a  store-house  for  furniture,  a  museum,  nor 
a  picture  gallery.  It  is  a  place  to  live  in  with  comfort  and  in  accord- 
ance with  hj'gienic  rules.  The  interior  furnishing,  therefore,  should 
be  simple  and  neat.  The  furniture,  and  only  so  much  of  it  as  is 
needed  for  comfort,  should  be  of  such  construction  as  not  to  gather 
dust.  Upholstered  furniture,  with  the  exception  of  plain  leather,  is 
unsanitary  and  should  not  be  tolerated.  The  floors  should  be  polished 
and  covered  with  rugs.  The  guiding  principle  in  all  cases  should  be 
a  maximum  of  space  and  a  minimum  of  dust. 


QUESTIONS  TO  CHAPTER  VI. 

CONSTRUCTION  OF  HABITATIONS. 

Why  should  the  principles  of  hygiene  be  observed  in  the  construction 
of  dwellings?  What  relation  is  there  between  badly-constructed  and  over- 
crowded dwellings  in  cities?  Between  overcrowded  dwellings  and  the  death- 
rate,  either  general  or  from  contagious  diseases?  What  class  of  persons  are 
especially  affected  by  overcrowding  and  unsanitary  conditions  of  their  dwell- 
ings? 

What  points  should  be  taken  into  consideration  in  building  a  house? 
What  things  are  to  be  sought  and  what  avoided  in  selecting  a  site  ?  On  what 
kind  of  soil  should  the  house  be  built?  Hov/  far  should  the  ground-water  be 
below  the  surface,  even  at  its  highest?  What  must  be  known  about  a  soil 
to  determine  whether  it  is  sanitarily  suitable  for  building  purposes?  What 
is  the  usual  judgment  concerning  sites  on  granite,  trap,  or  metamorphic 
rocks?  What  if  they  have  been  disintegrated?  What  regarding  those  on  the 
clay  slate?  Limestone  and  magnesian  limestone?  Chalk?  Sandstone?  Gravel? 
Sands?  Clays  and  alluvial  soils?  Cultivated  lands?  Which  of  the  above 
is  probably  the  best,  on  general  principles,  for  the  site  for  a  dwelling?  Where 
a  site  is  wet  or  the  soil  is  impure,  what  must  be  done?  What  is  the  mini- 
mum depth  at  which  drains  for  the  soil-water  should  be  laid?  How  else  may 
the  drying  of  the  soil  be  promoted?  How  should  a  cellar  or  basement  over 
an  impure  soil  be  paved?  What  precaution  should  be  observed  in  building  a 
house  against  a  hill? 

What  are  some  of  the  materials  of  which  the  walls  of  a  house  may  be 
built?  What  are  the  advantages  of  good  brick?  Why  should  very  porous 
sandstone  not  be  used  for  building  purposes  in  cold  climates  ?  What  is  the 
effect  of  paint  upon  houye-walls  ?  Has  calcimining  or  white-washing  the 
same  effect?  Has  wall-paper?  How  soon  should  newly-built  houses  be  occu- 
pied?   To  what  are  moist  walls  sometimes  due,  and  how  may  they  be  obviated? 

What  should  be  the  minimum  height  of  rooms  in  dwelling-houses?  How 
much  air-space  should  there  always  be  in  sleeping-rooms  for  adults  and  chil- 
dren? What  is  the  standard  of  purity  of  the  air  that  should  be  maintained 
constantly?  What  are  the  objections  to  heating  by  hot-air  furnaces,  and  how 
may  these  objections  be  avoided?  How  may  a  room  be  ventilated  without  ex- 
pensive apparatus? 

What  colors  should  be  avoided  in  wall-paper  and  paints  for  inside  work, 
and  why?  Wha.t  should  be  the  proportion  of  window-space  to  floor-space,  and 
what  other  points  should  be  observed  in  the  day-lighting  of  rooms?  What 
are  the  forms  of  artificial  light  used  for  household  illumination,  and  what  are 
the  dangers  accompanying  each  ?  What  are  some  of  the  especial  advantages 
of   the   incandescent  electric   light?     From   what   direction   should    the   light 

(217) 


218  QUESTIONS  TO  CHAPTER  VI. 

come  for  ^yriting,  reading,  etc.  ?  Why  must  there  be  increased  ventilation 
Avhere  artificial  lights  (except  incandescent  electric)  are  used?  How  much 
fresh  air  per  hour  is  needed  to  properly  dilute  the  impurities  produced  by 
burning  illuminating  gas? 

What  points  are  to  be  observed  regarding  the  water-supply  of  a  dwell- 
ing?    Why  should  it  be  both  abundant  and  convenient? 

How  are  waste-waters  and  excrementitious  matters  most  readily  re- 
moved from  a  house?  Where  would  it  be  best  to  have  all  fixtures,  etc., 
of  a  house-drainage  system  located,  if  possible?  What  do  water-closets,  etc., 
presuppose?  If  this  cannot  be  had,  what  system  should  be  adopted  instead? 
For  what  must  a  proper  house-drainage  system  provide?  What  are  the 
component  parts  of  such  a  system? 

Where  should  water-closets  never  be  located?  \^^iat  five  classes  of 
water-closets  are  there?  Which  of  these  are  most  objectionable,  and  why? 
Describe  briefly  the  construction  of  a  pan-  and  a  valve-  closet.  In  what  way 
is  a  plunger-closet  better  than  a  pan-  or  valve  closet?  Wherein  is  it  sani- 
tarily imperfect?  Why  is  the  hopper-closet  one  of  the  best?  What  two  kinds 
of  hopper-closet  are  there?  What  can  be  said  of  the  wash-out  closets?  What 
is  the  principle  of  siphon  closets?  Why  should  water-closets  and  other  fixtures 
not  be  inclosed  in  wooden  casings?  How  may  the  surroundings  of  such  closets 
and  fixtures  be  further  improved?  Why  should  the  water-supply  for  closets 
not  be  taken  directly  from  the  house-supply?  How  much  should  the  flushing 
cistern  hold  ? 

What  are  traps?  Where  should  they  be  located?  How  many  should 
there  be  in  any  system  of  house-drainage?  What  is  the  simplest  form  of 
trap?  What  are  its  advantages?  I'pon  what  does  the  value  of  a  trap  depend? 
What  is  to  be  avoided  in  the  selection  of  a  ti'ap?  What  is  meant  by  siphon- 
age?  How  can  this  be  prevented?  To  what  part  of  the  trap  is  the  vent-pipe 
to  be  attached?  Where  should  the  other 'end  of  the  vent-pipe  open?  How 
else  may  the  seal  of  a  trap  be  broken  ?  What  is  the  principle  of  McClellan's 
anti-siphon  trap? 

How  long  should  the  waste-pipe  connecting  the  fixtures  with  the  soil- 
pipes  be?  What  is  the  soil-pipe?  Of  what  dimensions  should  it  be?  Where 
should  its  upper  extremity  end?  What  other  precautions  should  be  observed 
in  regard  to  the  soil-pipe? 

What  is  the  house-drain?  What  care  must  be  observed  in  the  laying  of 
it?  What  can  you  say  regarding  a  trap  between  the  house-drain  and  sewer? 
If  a  trap  is  thus  located,  what  else  must  there  be  between  the  trap  and  the 
house,  and  why?  What  can  be  said  regarding  the  official  supervision  of  sani- 
tary arrangements  in  dwellings?  What  principle  should  underly  the  furnish- 
ing of  a  house? 


CHAPTER  VII. 

CONSTRUCTION  OF  HOSPITALS. 

SITE. 

If  the  choice  of  a  site  for  the  habitations  of  healthy  persons  is  a 
matter  of  vital  importance,  as  was  pointed  out  in  the  last  chapter, 
it  needs  no  argument  to  impress  upon  the  reader  the  actual  necessity 
of  choosing  a  site  with  wholesome  surroundings  for  a  habitation  for 
the  sick.  In  selecting  a  site  for  a  hospital,  therefore,  it  is  of  prime 
importance  to  avoid  a  location  where  unsanitary  influences  prevail. 

While  a  hospital  should  always  be  easily  accessible,  it  is  not 
desirable  that  it  should  be  in  a  noisy  or  crowded  part  of  a  city.  Where 
a  hospital  is  primarily  designed  for  the  reception  of  accident  or 
"emergency"  cases,  it  is,  of  course,  necessary  to  have  it  near  to  where 
accidents  are  likely  to  occur.  In  a  city  this  will  probably  be  in  the 
most  crowded  and  noisy  part. 

The  direction  of  the  prevailing  winds  from  the  city  should  be 
avoided  in  selecting  a  site  for  a  hospital. 

Free  admission  of  sunlight  and  air  must  be  secured  to  all  parts 
of  the  hospital.  An  elevated  location  is  therefore  desirable,  although 
exposure  to  violent  winds  must,  if  possible,  be  avoided. 

The  soil  upon  which  a  hospital  is  built  should  be  c^ean,  easily 
drained,  with  a  deep  ground-water  level,  not  liable  to  sudden  oscil- 
lations. The  neighborhood  of  a  marshy  or  known  malarious  region 
should  be  avoided. 

THE  BUILDINGS. 

The  building  area  must  be  large  enough  to  permit  the  construc- 
tion of  buildings  in  accordance  with  the  modern  recognized  principles 
of  hospital  construction.  Overcrowding  is  not  permissible,  either  of 
the  ground    by  buildings  or  of  the  buildings  by  patients. 

Hav'xig  determined  the  number  of  patients  for  whom  provision  is 
to  be  made  and  the  character  of  the  diseases  to  be  treated,  an  estimate 
must  be  made  of  the  area  necessary  for  a  hospital.  Taking  into  ac- 
count all  the  buildings  needed,  the  area  required  will  be— for  two 
or  more  storied  buildings — not  less  than  30  square  metres  per  bed. 

(219) 


220  TEXT-BOOK  OF  HYGIENE. 

If  one-story  buildings  are  to  be  erected  more  space  will  be  required, 
and  if  infectious  diseases  are  to  be  treated  in  the  hospital  the  above 
space-allowance  must  be  doubled  or  even  trebled.  In  the  Johns 
Hopkins  Hospital,  in  Baltimore,  the  area  occupied  by  the  buildings 
is  56,000  square  metres,  and  provision  is  to  be  made  for  300  patients. 
This,  covering,  of  course,  the  area  occupied  by  the  administration 
building,  nurses'  home,  kitchen,  dispensary,  operating  and  autopsy 
theatre,  laundry,  etc.,  gives  an  area  of  187  square  metres  per  bed. 
The  actual  allowance  of  floor  space  per  bed  is  IIV2  square  metres; 
for  patients  with  infectious  diseases  the  space-allowance  is  nearly 
treble,  being  29  square  metres. 

Within  recent  years  the  principles  of  hospital  construction  h:ive 
undergone  considerable  modification.  While  formerly  a  large  hospital 
consisted  usually  of  one  large,  two  or  more  storied  building,  in  which 
all  the  various  departments  were  comprised  under  one  roof,  the  aim  has 
recently  been  to  scatter  the  wards  as  much  as  practicable,  consistent 
with  reasonable  ease  of  supervision  and  administration.  Under  the 
former  plan,  with  large  wards  connected  by  common  corridors  and 
stairways,  ease  of  administration  was  primarily  secured;  in  the  lat- 
ter, the  most  important  object  of  a  hospital,  "a,  place  for  the  sick  to 
get  well  in,"  is  more  nearly  attained.  While  many  hospitals  are  still 
being  constructed  on  the  old  plan,  of  a  single  block  of  several  stories 
in  height,  nearly  all  sanitary  authorities  are  agreed  that  the  plan  of 
separate  pavilions  of  one  or,  at  most,  two  stories,  in  which  the  build- 
ings are  entirely  disconnected,  or  connected  only  by  means  of  an  open 
corridor  for  convenience  of  administration,  is  best  for  the  patients, 
and,  leaving  out  of  account  the  cost  of  the  ground,  is  also  the  most 
economical. 

The  recent  development  of  the  pavilion  system  of  hospitals  may 
be  attributed  largely  to  the  success  obtained  in  treating  the  sick  and 
wounded  in  the  simple  barrack  hospitals  during  the  late  war  between 
the  States.  The  army  barrack  hospital  is  the  original  type  of  the 
pavilion  hospital  of  the  present  day. 

Each  pavilion  consists  of  one  or  two  wards,  containing  from  ten 
to  thirty  beds  altogether.  In  each  pavilion  or  ward  is  also  a  bath- 
and  wash-  room,  water-closet,  dining-room,  scullery,  attendants'  room, 
and  sometimes  a  day-room  for  patients  able  to  be  out  of  bed. 

The  two-story  pavilion  is  built  on  the  same  plan,  and  is  generally 
adopted  in  cities,  or  where  economy  of  space  is  desirable  for  financial 
reasons,  and  where  no  infectious  diseases  are  treated.  Where  prac- 
ticable, one-story  pavilions  should  always  be  adopted,   as   they  are 


HOSPITAL  BUILDINGS. 


221 


more  easily  heated,  ventilated,  and  served  than  two-storied  buildings. 
When  a  number  of  pavilions  or  wards  are  connected  by  a  cor- 
ridor with  each  other,  and  with  a  central  or  administration  building 


WOLFE   ST. 


^  ^ 


]broa)dv^ay^ 


Fig.  26. — Plan  of  Johns  Hopkins  Hospital.  A,  Administration 
Building.  B,  Female  Pay-ward.  C,  Male  Pay-v/ard.  D,  Male  Surgical 
Ward.  E,  Female  Surgical  Ward.  F,  Male  Medical  Ward.  G,  Female 
Medical  Ward.  B.,  Gynecological  Ward.  /,  Isolating  Ward.  K, 
Kitchen.  L,  Laundry.  'N ,  Nurses'  Home.  0,  Dispensary.  R,  Patho- 
logical Building.  »?,  Stable.  TJ ,  Amphitheatre.  X,  Apothecary's 
Building.     Y,  Bath-house. 


and  other  service  buildings,  the  aggregation  constitutes  a  modem 
pavilion  block-hospital.  The  Johns  Hopkins  Hospital,  already  refer- 
red to,  is  a  model  of  this  class,  and  its  plans  should  be  studied  in  detail 
by  all  who  are  more  particularly  interested  in  hospital  construction. 


222  TEXT-BOOK  OF  HYGIENE. 

The  general  wards  are  in  one-  and  two-  story  buildings,  connected 
by  a  corridor  with  each  other  and  with  the  administration  and  ser- 
vice buildings.  In  addition  to  two  buildings  containing  private 
rooms  and  small  wards  for  patients  able  to  pay  for  the  extra  accom- 
modations, there  is  a  line  of  paviaons  running  from  east  to  west.  The 
corridor  cuts  all  the  pavilions  near  the  north  ends  of  the  buildings, 
separating  the  ward  almost  entirely  from  the  service  part  of  the 
building.  This  arrangement  leaves  the  south,  east,  and  west  fronts 
of  the  wards  entirely  exposed  to  the  sun's  rays — a  very  important 
advantage.  The  kitchen  and  laundry  are  at  opposite  angles  of  the 
grounds,  while  the  autopsy  building  is  placed  in  the  extreme  north- 
east corner  of  the  grounds,  as  far  from  all  the  wards  as  practicable. 
The  free  space  between  the  separate  pavilions  should  be  at  least 
twice  the  height  of  the  building.  In  the  Johns  Hopkins  Hospital, 
the  space  is  18  metres  between  the  one-story  common  wards,  which 
are  11  metres  in  height  from  the  surface  of  the  ground  to  the  ridge 
of  the  roof. 

VENTILATION  AND   HEATING. 

The  cubic  space  (initial  air-space)  per  bed  in  the  wards  should 
not  be  less  than  1500  to  2000  cubic  feet  (42  to  56  cubic  metres),  and 
for  surgical  or  lying-in  cases  and  contagious  diseases,  70  cubic  metres 
should  be  allowed.  The  ventilating  arrangements  should  secure  an 
entire  change  of  the  air  two  to  three  times  an  hour. 

In  most  sections  of  the  United  States,  natural  ventilation  can 
be  relied  on  to  keep  the  air  in  hospital  wards  pure  (assuming,  of 
course,  the  proper  construction  of  the  buildings).  The  windows, 
doors,  and  walls  are  important  factors  in  securing  this  ventilation. 
Hence,  especial  care  is  to  be  paid  to  their  construction  and  arrange- 
ment. 

Many  German,  French,  and  English  authorities  on  hospital 
building  urge  the  importance  of  making  the  walls  impervious  by 
cement,  glass,  or  paint.  The  peculiar  odor  known  as  ^Tiospital  odor," 
it  is  asserted,  cannot  be  prevented  in  any  hospital  in  which  the  floors, 
walls,  and  ceilings  are  not  absolutely  impervious.  The  American 
practice  is  generally  in  favor  of  walls  which  permit  transpiration  of 
air.  In  the  experience  of  the  author  the  imperviousness  of  the  walls 
is  not  necessary  to  secure  freedom  from  hospital  odor.  It  remains 
a  question  for  serious  consideration  whether  the  diminution  of  natural 
ventilation  would  not  counterbalance  any  good  resulting  from  non- 
absorptive  walls. 


VENTILATION  AND  HEATING.  '  223 

The  interior  of  the  walls  shouM  be  perfectly  smooth  and  plain; 
no  projections,  cornices,  or  offsets  of  any  kind  are  permissible.  The 
desirability  of  this  restriction  was  clearly  expressed  over  a  hundred 
years  ago  by  John  Howard :  "From  a  regard  to  the  health  of  the 
patients,  I  wish  to  see  plain,  white  walls  in  hospitals,  and  no  article 
of  ornamental  furniture  introduced."^ 

Windows  should  run  quite  to  the  ceiling,  and  should  not  be 
arched,  but  finished  square  at  the  top.  There  should  be  one  window 
for  every  two  beds.  The  window-sash  should  be  double  to  retain  heat, 
and  the  lights  heavy,  clear  glass.  Ventilation  can  be  promoted  by 
raising  the  outer  sash  from  below  and  lowering  the  inner  one  from 
above.  The  insertion  of  a  Sherringham  ventilator  at  the  top  of  the 
inner  sash  will  aid  in  giving  the  incoming  air-current  an  upward 
direction. 

Heating  is  best  accomplished  by  introducing  hot  air  from  without, 
or  by  stoves  or  fire-places  in  the  centre  of  the  wards.  Where  hot  air 
is  introduced  from  without,  it  should  be  heated  by  passing  it  over 
steam  or  hot-water  coils,  and  not  by  passing  it  through  a  furnace, 
which  may  produce  super-heating  and  excessive  dryness  of  the  air. 

In  a  series  of  experiments  by  Dr.  Edward  Cowles  at  the  Boston 
City  Hospital,^  the  air  was  heated  to  33°  C.  by  passing  it  over  steam- 
coils.  It  was  admitted  to  the  wards  by  numerous  inlets  30  centimetres 
square.  The  best  velocity  for  ventilating  and  warming  purposes  was 
found  to  be  54  metres  per  minute.  Exit  openings  were  in  the  ceil- 
ing, and  it  was  found  best  to  make  them  large,  as  by  this  means  the 
rapidity  of  exit  currents  is  reduced. 

Where  the  warming  of  the  ward  must  be  accomplished  by  stoves 
or  fire-places  in  the  ward,  the  best  plan,  for  square  and  octagon  wards, 
is  to  have  a  large  central  chimney  with  arrangements  on  the  four 
sides  for  fire-places  or  stoves.  This  chimney  can  also  be  used  as  a 
very  efficient  ventilating  shaft  throughout  the  year  by  a  device  put 
in  practice  by  Mr.  John  E.  Neirnsee,  architect  of  the  Johns  Hopkins 
Hospital.^  In  oblong  wards,  two  or  more  large  stoves,  placed  at  equal 
distances  along  the  centre  of  the  wards,  will  heat  the  wards  effectually. 

Floors  should  be  made  of  tiles,  slate,  or  oak  or  yellow-pine 
lumber.    If  wood  is  used,  it  should  be  well  seasoned,  perfectly  smooth. 


'  An  Account  of  the  Principal  Lazarettos  of  Europe,  etc.,  p.  57.  London, 
1791. 

^Report  of  the  Massachusetts  State  Board  of  Health  for  1879,  pp.  231- 
248. 

'  Hospital  Construction  nnd  Orcranization :  Plans  for  Johns  Hopkins 
Hospital,  p.  .3.3.5  et  seq.     New  York,  187.5.  ^ 


224  TEXT-BOOK  OF  HYGIENE. 

and  all  joints  accurately  made.  The  floor  should  be  kept  constantly 
waxed  to  render  it  impervious  to  fluids. 

The  space  between  the  floor  and  ceiling  below  should  be  filled 
with  some  fire-proof  non-conducting  material,  such  as  cement  or  hol- 
low bricks,  in  order  to  isolate  each  floor  or  ward,  as  much  as  possible 
from  others,  both  to  prevent  transmission  of  noise  and  extension  of 
fire. 

All  corners  and  angles,  on  the  inside  of  the  building  should  be 
rounded  to  facilitate  the  removal  of  dust. 

In  c.eaning  up,  care  should  be  taken  not  to  stir  up  the  layers 
of  dust  too  much  by  active  sweeping  and  dusting.  The  floors,  fur- 
niture, door-  and  window-  casings  should  be  wiped  off  with  damp 
cloths.  Soiled  bedding,  clothing,  dressings,  and  bandages  must  be 
promptly  removed  from  the  ward.  Mattresses  and  other  bed-clothing 
should  not  be  shaken  in  the  ward.* 

Water-closets  or  (where  the  dry  method  of  removal  of  excreta  is 
in  use)  earth-  or  pail-  closets  should  be  placed  where  they  can  be 
easily  reached  by  the  patients,  but  the  apartment  in  which  they  are 
placed  must  not  open  directly  into  the  ward.  The  entrance  to  this 
apartment  should  be  from  the  corridor  or,  better  still,  from  the  open 
air.  The  ventilation  of  water-closets  should  be  independent  of  and 
entirely  distinct  from  that  of  the  ward  or  other  part  of  the  hospital 
building. 

It  is,  of  course,  unnecessary  to  more  than  call  attention  to  the 
vital  importance  of  the  prompt  removal  of  all  excreta,  both  solid  and 
liquid,  from  the  ward  or  hospital  building.  To  attempt  disinfection 
of  excreta  and  allow  them  to  remain  in  the  ward  after  being  voided 
is  a  pernicious  practice,  which  should  under  no  circumstances  be  per- 
mitted. All  utensils  for  the  reception  of  excreta,  bed-pans,  etc., 
should  be  immediately  emptied  and  thoroughly  cleansed. 

Urinals  are  not  advisable ;  the  simple  hopper-closet  with  hinged, 
hard-wood  seat,  as  described  in  Chapter  VI,  is  sufficient. 

A  bath-room  and  lavatory  should  be  attached  to  every  ward.  It 
should  be  placed  in  the  service  building,  and  be  easily  accessible  to 
the  patients.  There  should  also  be  portable  bath-tubs  in  order  that 
baths  may  be  given  in  the  wards  when  necessary. 

Every  large  general  hospital  should  also  have  a  special  apart- 
ment or  building  where  baths  of  various  kinds,  such  as  medicated, 
vapor,  Turkish,  and  Eussian  baths,  could  be  given.     In  lying-in  hos- 


*A.  Wernich:     Ueber  Verdorbene  Luft  in  Krankenraeumen.     Volkmann's 
Samml.  Klin.  Vortr.,  No.  179,  p.  24. 


VENTILATION  AND  HEATING.  225 

pitals,  special  arrangements  for  giving  vaginal  and  uterine  douches 
must  also  be  furnished. 

A  daily  water-supply  of  at  least  450  litres  per  bed  should  be  pro- 
vided. The  water  should  be  easily  accessible  from  the  wards  and 
various  parts  of  the  service  building. 

All  water-closets,  soil-  and  waste-pipes  must  be  properly  trapped ; 
all  joints  must  be  properly  made  and  all  sewer  connections  made  on 
the  most  improved  plans.  All  work  of  this  sort  should  be  properly 
tested  before  being  accepted,  and  frequently  inspected  afterward. 

No  sewer  or  house-drain  should  be  laid  under  a  ward. 

A  disinfecting  chest  for  disinfecting  soiled  clothing,  bedding, 
dressings,  etc.,  should  be  placed  in  the  basement  of  the  ward,  and 
connected  with  the  latter  by  an  iron  chute,  closing  perfectly  by  an 
iron  top.  The  best  and  most  convenient  disinfectant  is  steam.  This 
is  also  the  best  means  to  destroy  vermin  in  clothing  and  bedding. 

It  is  questionable  whether  a  nurse's  room  should  be  attached  to  a 
hospital  ward.  The  nurse's  place,  when  on  duty,  is  in  the  ward  itself, 
not  in  a  room  separate  from  it.  Where  there  is  a  nurse's  room,  it 
should  not  be  furnished  with  sleeping  arrangements,  for  this  is  a 
strong  temptation  to  neglect  of  duty  on  the  part  of  the  nurse.  A 
nurse  not  on  duty  should  not  be  permitted  to  remain  about  the  ward. 

A  ward-kitchen  should  be  in  the  service  building,  where  articles 
of  food  can  be  kept  hot  or  cold  when  necessary,  and  where  special 
dressings,  cataplasms,  hot  water,  etc.,  can  be  prepared.  'A  small  gas- 
stove  only  should  be  allowed  in  the  ward-kitchen,  as  the  regular  meals 
of  the  patients  are  prepared  in  the  central  kitchen,  which  should 
be  totally  detached  from  the  hospital.  The  ward-kitchen  can  be 
easily  utilized  as  a  nurse's  room,  and  in  a  small  hospital  can  also 
be  used  as  a  store-room  for  the  patients'  body-  and  bed-  linen  and 
clothing. 

The  dining-room  for  patients  able  to  be  out  of  bed  should  be 
in  the  service  building.  A  room  with  a  good  light  and  well  ventilated 
and  heated  should  be  selected  for  this  purpose.  In  the  intervals 
between  meals  this  room  could  be  used  as  a  day-room  for  such  patients 
as  should  be  out  of  bed,  but  who  are  not  able  to  be  in  the  open  air. 

A  dead-house,  containing  a  dead-room,  autopsy-room,  and  a  room 
fitted  up  for  rough  microscopic  and  possibly  photographic  work,  is 
a  necessity  to  every  well-appointed  general  hospital.  The  doad-house 
should  be  entirely  separate  from  the  ward  buildings. 

The  kitchen  should  be  separate  from  the  other  buildings,  and 
in  large  hospitals  shoidd  also  bo  the  central  station  for  the  heating 


226  TEXT-BOOK  OF  HYGIENE. 

arrangements,  if  hot  water  or  steam  is  to  be  used.  The  laundry  may 
be  connected  with  it.  The  kitchen  should  be  connected  with  the 
wards  by  means  of  a  covered  corridor  to  avoid  exposure  in  carrying 
the  food  to  the  wards. 

The  administration  building  should  contain  office-rooms  for  the 
superintendent  and  resident  physician,  pharmacy,  library,  reception- 
rooms  -for  visitors,  living-rooms  for  one  or  more  assistants,  and  dwell- 
ings for  the  superintendent  and  resident  physician. 

THE  ADMINISTRATION  AND   MANAGEMENT  OF  A  GENERAL 

HOSPITAL. 

The  general  management  of  a  hospital  should  be  under  the  direc- 
tion of  a  superintendent,  who,  besides  being  a  medical  man,  should  be 
especially  qualified  by  study  and  experience  for  the  work.  The  super- 
intendent of  a  large  hospital  should  not  be  expected  to  perform  any 
of  the  routine  professional  work  in  the  wards,  but  he  should  be  re- 
sponsible for  the  service,  both  professional  and  lay,  in  the  hospital. 
He  should  be  the  financial  officer,  and  in  all  other  things  concerning 
the  hospital  his  judgment  should  decide.  He  should  have  sufficient 
assistance  to  permit  all  necessary  duties  to  be  promptly  performed. 
For  this  purpose  he  should  have  a  secretary,  or  clerk,  who  should  not 
be  a  medical  man;  otherwise  the  attention  of  the  latter  mighu  be 
withdrawn  from  his  clerical  duties  to  the  more  interesting  profes- 
sional work  in  the  hospital.  The  plan  advocated  by  some  authorities, 
to  have  two  superintendents  for  large  hospitals — one  of  whom  shall 
be  a  medical  man  and  direct  only  the  professional  work  of  the  hos- 
pital, while  the  other  shall  have  charge  of  the  administrative  func- 
tions— does  not  commend  itself  to  the  author.  It  involves  a  division 
of  responsibility  which  will,  in  nearly  all  cases,  eventually  lead  to 
differences  of  opinion  likely  to  prove  unfavorable  to  the  best  interests 
of  the  hospital. 

It  is  customary  in  this  country  to  appoint  as  resident  physicians 
and  surgeons  in  hospitals,  recent  graduates,  whose  functions  are  usu- 
ally limited  to  carrying  out  the  directions  of  the  visiting  physicians 
and  surgeons,  and  sometimes  to  act  on  their  own  responsibility  in 
emergencies.  This  system  has  some  advantages  for  the  physicians,  but 
is  usually  detrimental  to  the  best  interests  of  the  patients.  The 
resident  medical  officer  in  a  large  hospital  should  always  be  a  thor- 
oughly qualified,  experienced  physician,  capable  of  deciding  promptly 
when  the  occasion  arises,  and  he  should  be  responsible  to  the  super- 


ADMINISTRATION  AND  MANAGEMENT  OF  HOSPITAL.         227 

intendent  for  the  proper  performance  of  his  professional  duties. 
Necessarily,  a  physician  with  the  qualifications  indicated,  would  de- 
mand a  very  much  larger  salary  than  is  usually  paid  resident  physi- 
cians, but  it  should  be  understood  that  no  hospital  in  which  the  good 
of  the  patient  is  the  first  consideration  can  be  conducted  on  a  cheap 
basis. 

Visiting  physicians  and  surgeons  and  all  resident  medical  officers 
should  be  chosen  with  reference  to  their  general  and  special  quali- 
fications for  the  duties  expected  of  them.  It  would  seem  to  be  a  good 
plan  to  make  the  selections  for  subordinate  positions,  at  least,  by  com- 
petitive examination. 

The  sick  in  a  hospital  should  be  properly  classified.  Male  and 
female  patients  should,  of  course,  be  treated  in  separate  wards.  A 
primary  classification  into  medical,  surgical,  and  obstetrical  cases  or 
wards  is  also  indicated.  Infectious  diseases,  such  as  typhoid  fever, 
erysipelas,  cholera,  yellow  fever,  croupous  pneumonia,  etc.,  should  not 
be  treated  in  the  same  wards  with  rheumatism,  Bright's  disease,  car- 
diac and  nervous  disorders,  or  simple  digestive  derangements.  It  is 
questionable,  however,  whether  it  is  advisable  to  make  a  very  elaborate 
classification  of  the  various  diseases  except  in  very  large  hospitals. 

An  accurate  record,  made  at  the  time  of  observation,  and  not 
written  from  memory  afterward,  should  be  kept  of  the  history  and 
progress  of  every  case.  The  record  should  show  not  merely  the  symp- 
toms and  diagnosis,  but  the  medical  and  hygienic  treatment.  In  most 
hospitals  where  such  records  are  kept  the  entries  are  made  either  in 
a  simple  memorandum-book  or  in  a  more  or  less  complicated  case- 
record.  A  simple  form  of  case-record  has  been  devised  by  Surgeon- 
General  Walter  Wyman,  of  United  States  Marine-Hospital  Service, 
which  seems  to  possess  advantages  that  render  its  general  adoption 
desirable. 

In  hospitals  where  cases  of  surgical  diseases  and  injuries  are  re- 
ceived, a  special  apartment  should  be  fitted  up  as  an  operating-room. 
Operations  should  not  be  performed  in  a  ward  in  the  presence  of 
other  patients. 


QUESTIONS  TO  CHAPTER  VII. 

CONSTRUCTION  OF  HOSPITALS. 

What  would  govern  you  in  selecting  a  site  for  a  hospital?  What  will 
go  to  determine  the  building  area?  In  calculating  the  area  required  for 
buildings,  what  relation  has  it  to  the  number  of  beds  in  the  hospital?  In 
the  wards,  what  should  be  the  actual  minimum  floor-space  for  each  bed  for 
non-infectious  and  for  infectious  diseases?  What  is  the  difference  in  the 
principles  of  modern  hospital  construction  and  of  those  formerly  in  vogue? 
What  are  some  of  the  advantages  of  the  modern  plan?  What  was  the  pro- 
totype of  the  present  system?  How  many  wards  should  each  pavilion  contain 
at  the  most?  How  many  beds  in  each  ward?  What  conveniences  should  there 
be  in  each  ward  or  pavilion?  What  is  meant  by  a  pavilion  block-hospital? 
What  space  should  there  be  between  the  separate  pavilions? 

What  cubic  space  per  bed  should  there  be  in  the  ordinary  wards?  What 
cases  need  more,  and  how  much?  How  often  should  the  air  be  entirely 
changed  in  the  wards?  Should  the  walls  be  pervious  or  impervious  to  the 
passage  of  air?  How  should  the  walls  be  finished?  How  many  windows 
should  there  be  in  each  ward?     How  high  should  they  be? 

\\'Tiat  is  the  best  way  to  heat  a  hospital  ward?  How  should  hot  air 
be  warmed?  If  a  ward  is  to  be  warmed  by  fire-places  or  stoves,  how  should 
they  be   arranged? 

Of  what  materials  should  the  floors  be  made?  How  should  they  be 
treated?  Wliat  should  there  be  between  ceilings  and  the  floors  above?  Why? 
How  should  the  corners  and  angles  of  floors  and  ceilings  be  finished? 

How  should  the  wards  be  cleaned?  What  should  be  done  with  soiled 
bedding,   etc.  ? 

Where  should  the  water-closets,  etc.,  be  located?  How  should  they  be 
ventilated  ? 

How  much  water  should  be  furnished  per  bed?  Why  should  no  sewer 
or  house-drain  be  laid  under  a  ward?  Where  should  the  nurses'  rooms  be? 
Where  the  ward  kitchen  and  dining-room?  What  is  the  administration 
building  for,  and  what  should  it  contain  ?  What  officers  are  necessary  for 
the  management  of  a  hospital?  What  are  their  duties?  How  should  the 
resident  physicians  be  qualified  and  selected?  How  should  the  sick  be  classi- 
fied, and  what  wards  should  there  be  in  a  general  hospital?  Mention  some 
of  the  details  that  should  be  noted  in  the  case  records. 


(228) 


CHAPTER  VIII. 

SCHOOL  HYGIENE. 

During  the  period  of  childhood  and  youth  the  organism  yields 
readily  to  impressions  and  forces,  both  external  and  internal,  and  it  is 
therefore  important  that  the  child  be  safeguarded  during  this  forma- 
tive period,  and  surrounded  with  those  influences  which  make  for  good. 
Considering  the  number  of  years  spent  in  acquiring  an  education  and 
the  length  of  time  each  day  devoted  to  study,  most  of  which  is  spent  in 
the  school-room,  it  will  be  readily  understood  why  a  special  chapter 
should  be  devoted  to  this  particular  theme.  School  hygiene  includes 
the  consideration  of  the  sanitary  principles  underlying  the  construction 
of  school-houses  and  school-furniture,  ventilation  and  heating;  the 
proper  amount  of  time  to  be  devoted  to  study  at  different  ages;  the 
special  diseases  of  school-children,  their  causes,  and  means  for  their 
prevention.  It  also  embraces  the  personal  hygiene  of  the  scholar 
and  his  g'eneral  health  and  habits. 

These  matters  are  of  interest  to  the  scholar  himself,  to  his 
parents,  the  citizen  in  general,  and  especially  to  the  physician;  be- 
cause as  a  physician  he  is  specially  fitted  by  his  special  education 
and  training  to  serve  on  school-boards  and  committees  of  education, 
and  because  he  is  so  often  called  on  to  treat  those  maladies  of  child- 
hood which  have  been  caused  by  unsanitary  conditions  in  school  life, 
or  are  largely  influenced  thereby. 

In  the  construction  of  school-houses  the  same  hygienic  principles 
are  applicable  as  in  dwelling-house  construction.  The  selection  of  a 
site  for  the  school-building  should  command  the  same  careful  con- 
sideration that  is  necessary  in  determining  upon  a  site  for  a  dwelling. 
It  should  be  of  sufficient  elevation  to  insure  good  drainage,  not  only  of 
the  sewage  and  refuse  collected  in  the  building,  but  also  of  surface- 
and  rain-  water  flowing  over  the  soil.  Proximity  to  marshes  and 
other  unsanitary  surroundings  should  be  avoided.  If  the  soil  is  damp 
it  should  be  properly  drained,  and  all  sources  of  insalubrity  in  the 
neighborhood   avoided   or,   if  possible,   removed. 

Especially  should  there  be  plenty  of  space  around  the  building 
to  insure  good  external  ventilation,  to  insure  the  admission  of  an 
abundance   of   light,    and   to   provide    ample   play-grounds    for   the 

(229) 


230  TEXT-BOOK  OF  HYGIENE. 

children.     School-buildings  should  not  be  located  in  close  proximity 
to  factories,  or  to  trades  giving  off  smoke,  dust,  or  noxious  odors. 

School-houses  should  not  be  over  three  stories  high;  corridors 
and  stairways  should  be  wide,  straight,  and  well  lighted.  All  stairs 
should  be  securely  built,  and  be  guarded  with  ample,  strong  railing. 
All  doors  should  open  outward  to  permit  ready  egress  and  reduce  the 
danger  of  accident  in  panics  from  any  cause. 

Fire-drills  should  be  held  at  stated  intervals  under  direction  of 
the  teachers. 

In  addition  to  the  study-  or  recitation-  rooms,  provision  should 
be  made  for  play  and  calisthenic-exercise  rooms.  Well-lighted  and 
ventilated  side-rooms  should  be  provided  for  the  reception  of  out- 
side clothing,  umbrellas,  overshoes,  etc.  These  articles  should  not  be 
kept  in  the  recitation-  or  study-  rooms. 

Floors  should  be  made  of  accurately-joined  flooring,  and  ren- 
dered impervious  by  oil  or  paraffine  coating. 

All  corners  and  angles  should  be  rounded,  to  prevent  the  accu- 
mulation of  dirt. 

Appropriate  measures  must  be  employed  to  prevent  the  permea- 
tion of  the  building  by  ground-air. 

The  foundation-walls  should  be  laid  in  Portland  cement,  and 
coated  inside  and  out  with  the  same,  and  the  floors  should  be  laid 
in  at  least  ten  inches  of  cement.  This  will  insure  a  damp-proof 
basement  as  well,  which  may  be  used  as  play-rooms  during  in- 
clement weather,  provided  they  be  properly  heated  and  ventilated. 

The  inside  walls  of  school-rooms  may  be  tinted  a  neutral  gray, 
or  light  blue  or  green.  Ceilings  should  be  white.  Walls  and  ceil- 
ings should  not  be  painted,  but  lime-coated  to  permit  free  transpira- 
tion of  air. 

Schools  should  be  so  constructed  as  to  permit  of  ready  heating 
and  ventilation,  cleaning,  and  keeping  clean.  In  large  schools  the 
method  will  usually  be  by  furnace-heated  air,  although  a  better 
method  would  probably  be  by  steam-  or  hot-water  pipes. 

What  is  known  as  the  "Smead  system"  is  a  most  excellent  one. 
It  is  a  combined  system  of  heating  and  ventilation,  consisting  of  a 
hot-air  furnace,  the  fresh  heated  air  being  admitted  through  one  set 
of  registers,  placed  in  the  wall  near  the  floor,  and  the  foul  air  being 
taken  out  through  another  set  of  flues  on  the  same  side  of  the  room 
and  at  the  same  level.  This  "used-up''  air  is  then  carried  from  the 
building  through  a  system  of  ducts  passing  beneath  the  floors  of 
the  rooms,  the  heat,  by  this  arrangement,  being  further  utilized  to 


SCHOOL  HYGIENE. 


231 


heat  the  floors  as  it  escapes.  In  rural  districts  the  school-room  may 
be  heated  by  means  of  a  stove,  provided  with  a  jacket  or  cylinder 
surrounding  it,  and  several  feet  in  heidit.     This  is  made  of  tin  or 


Fig.  27. 


Fig.  28. 


Fig.  27. — a,  a,  Sash,  b,  h,  Window-jambs,  c,  c,  Window-sill.  This 
cut  represents  the  view  from  within  the  Bury  Ventilator,  in  operation. 
It  is  broken  away  at  one  end  to  show  the  sash  raised  above  the  outer 
holes  to  admit  the  air. 

Fig.  28. — a,  a,  Sash.  This  cut  represents  the  view  from  without 
the  Bury  Ventilator,  in  operation.  The  sash  is  broken  away  to  show 
the  ventilator  behind,  with  the  fresh  air  passing  in. 


zinc.     In  the  floor,  beneath  the  stove,  ho^es  are  bored  to  admit  fresh 
air,  which,  warmed  in  passing  over  the  stove,  is  deflected  upward, 


and  diffused,  by  means  of  the  jacket. 


232  TEXT-BOOK  OF  HYGIENE. 

The  ventilation  of  school-rooms  must  be  carried  out  on  the 
principles  indicated  in  Chapter  I.  With  careful  and  intelligent 
teachers,  natural  ventilation  will  give  better  satisfaction  than  a  com- 
plicated artificial  system.  Where  windows  and  doors  must  be  largely 
depended  upon  for  ventilation,  the  Bury  window  ventilator,  here 
illustrated,  will  give  satisfactory  results  unless  the  school-room  is 
overcrowded. 

Opening  the  doors  and  windows  when  the  pupils  are  out  of  doors 
— flushing  the  rooms  with  fresh  air — is  not  a  method  to  be  com- 
mended. The  temperature  of  the  room  is  so  lowered,  that  when  the 
children,  overheated  from  play,  return  to  it,  they  may  become  chilled, 
and  "colds"  be  produced. 

A  model  study-room,  according  to  modern  views,  should  be 
about  9  to  10  metres  long,  not  over  7  metres  wide,  and  4  to  4  ^/g 
metres  high.  Such  a  room  could  be  easily  lighted  by  windows  on  one 
side  only,  and  readily  heated  and  ventilated.  It  wouM  also  enable 
the  teacher  to  exercise  a  close  supervision  over  the  pupils.  In  a 
room  of  this  size  forty  pupils  would  be  a  proper  number,  although 
fifty  could  be  accommodated.  The  initial  air-space  for  each  pupil 
would  be  5.60  cubic  metres  if  there  were  fifty  pupils  in  the  room, 
and  7  cubic  metres  if  there  were  only  forty.  This  would  be  slightly 
reduced  by  allowance  for  the  teacher. 

It  is  believed  that  study-rooms  should  face  toward  the  north. 
The  light  entering  from  the  north  side  of  a  building  would  be 
equable  during  a  whole  day.  While  a  larger  window  surface  would 
be  necessary  than  with  an  easterly  or  southerly  exposure,  it  is  held 
that  the  light,  being  devoid  of  all  glare,  would  be  more  effective. 
When  the  light  is  admitted  on  the  east,  south,  or  west  sides  of  the 
building,  the  direct  entrance  of  the  sun's  rays  must  be  prevented 
by  curtains,  by  means  of  which  the  amount  and  proper  distribution  of 
the  light  is  regulated  with  difficulty. 

The  windows  of  the  school-room  should  reach  from  about  the 
height  of  the  pupil's  shoulder  (when  seated)  to  the  ceiling.  Arches 
or  overhanging  cornices  over  the  windows  should  be  avoided,  as  they 
cut  off  much  light.  For  the  same  reason  the  near  proximity  of  other 
high  buildings  and  of  trees  should  be  avoided  in  selecting  a  site  for  a 
schoolhouse.  The  window  area  should  be  not  less  than  one-fifth  of 
the  floor  area,  otherwise  the  light  will  be  deficient. 

The  light  should  be  admitted  only  from  the  left  side  of  the 
pupil.  When  admitted  from  the  right  side  the  shadow  cast  by  the 
pen  in  writing  interferes  with  good  vision;    if  admitted  directly  in 


SCHOOL  HYGIENE.  233 

front  of  the  pupil,  the  glare  of  the  light  will  injuriously  affect  the 
eyes;  while,  if  it  can  enter  from  behind,  the  book  or  paper  of  the 
pupil  will  be  so  much  in  shadow  as  to  compel  him  to  lean  so  far  to 
the  front  in  bringing  his  eyes  nearer  to  book  or  paper  that  nearsight- 
edness is  very  likely  to  be  developed.  Furthermore,  if  the  light  is 
admitted  into  the  room  at  the  backs  of  the  pupils,  the  eyes  of  the 
teacher  are  liable  to  suffer  from  the  constant  glare. 

In  a  school-room  of  the  dimensions  above  stated,  a  row  of  windows 
on  one  side,  forming  an  area  of  glass  of  one-fifth  of  the  floor-space, 
will  thoroughly  and  satisfactorily  illuminate  the  room,  with  the  least 
unfavorable  influence  upon  the  organs  of  vision.  It  is  advisable, 
therefore,  to  always  insist  upon  this  arrangement  of  lighting  of 
school-rooms.  Where  artificial  light  is  used  in  a  school-room,  it 
should  be  in  the  proportion  of  one  burner  to  every  four  pupils. 
All  burners  should  be  provided  with  chimneys  and  vertical  re- 
flectors. 

Electric  lights,  properly  shaded,  or  toned  down  with  ground  glass 
or  tinted  globes,  are  to  be  preferred,  as  they  do  not  require  any 
additional  ventilation. 

Water-closets  and  privies  should  not  be  placed  in  cellars  or 
basements.  This  would  seem  to  be  self-evident,  and  yet  in  many  city 
school-houses  these  places  of  retirement  are  in  this  unsuitable  loca- 
tion. When  it  is  considered  that  large  schools  are  frequently  warmed 
by  hot  air  taken  from  the  cellar,  it  furnishes  an  additional  reason 
to  avoid  this  location  for  water-closets.  On  the  contrary,  the  cus- 
tom, in  some  country  schools,  of  placing  the  privy  at  a  considerable 
distance  from  the  school-room  and  in  an  exposed  situation  is  almost 
equally  reprehensible,  as  the  pupils,  especially  girls,  are  prone  to 
neglect  obeying  the  calls  of  nature,  from  which  neglect  many  dis- 
orders arise.  These  "garden-houses"  should  be  connected  with  the 
school-house  by  a  covered  way. 

Desks  should  be  slightly  sloping,  the  edge  nearest  the  pupil  being 
about  1  inch  (2.5  centimetres)  higher  than  his  elbows.  The  front 
edge  of  the  seat  should  project  a  little  beyond  the  near  edge  of  the 
desk,  so  that  a  plumb-line  dropped  from  the  latter  should  strike  the 
seat  near  its  front  edge.  If  the  seat  is  not  thus  brought  slightly 
under  the  desk,  the  pupil  is  compelled  to  lean  forward  in  writing, 
which  position  prevents  proper  expansion  of  the  chest  and  increases 
the  bloofl-pressure  in  the  eyes — a  condition  promotive  of  near- 
sightedness. 

Seats  should  be  only  high  enough  so  that  the  feet  rest  flat  upon 


234 


-TEXT-BOOK  OF  HYGIENE. 


the  floor.  If  they  are  higher^  a  foot-board  must  be  provided. 
Children  should  not  be  condemned  to  the  cruelty  of  having  their 
feet  dangling  "between  heaven  and  earth"  while  they  keep  their  seats. 
Seats  and  desks  should  be  graded  according  to  the  sizes  of  the  pupils — 
not  their  ages  or  standing  in  the  class. 

An  ideal  seat  and  desk  would  be  one  made  to  measure  for  each 
pupil,  but  this  is  manifestly  impracticable,  inasmuch  as  with  the 
constant  growth  of  the  child  the  seats  would  be  rapidly  outgrown. 


Fig.   29. — Adjustable  School-desk    (Front  View). 


The  desk  shown  in  Fig.  29^  is  adjustable  to  children  of  differ- 
ent sizes,  and  seems  to  solve  the  problem  which  has  so  long  puzzled  the 
school  sanitarian.  The  desks  are  made  for  a  single  pupil  and  the 
seat  and  desk  are  independently  adjustable.  The  frame  is  of  iron 
and  the  seat,  back,  and  desk  of  hard-wood  lumber. 

Blackboards  should  not  be  placed  at  a  greater  distance  than  10 
metres  from  the  farthest  pupil.  The  ground  of  the  board  should  be 
a  dead  black,  without  lustre.  In  writing  exercises  upon  the  board, 
care  should  be  taken  that  the  letters  and  figures  are  made  sufficiently 
large,  and  with  rather  heavy  strokes  of  the  crayon,  in  order  that 
they  may  be  easily  seen  from  the  most  distant  part  of  the  room.    It 


S.  A. 


'  Made  by  the  Rushville  bchool  Furniture  Company,  Rushville,  Ind.,  U. 


SCHOOL  HYGIENE.  235 

has  recently  been  demonstrated  that  a  black  letter  on  a  white  ground 
can  be  seen  at  a  greater  distance  than  a  white  letter  on  a  black 
ground.  Hence,  it  might  prove  advantageous  to  the  eye-sight  of 
school-children  to  substitute  for  the  present  blackboard  and  chalk, 
a  white  board  and  black  crayon.  In  some  European  lecture-rooms 
this  plan  has  been  adopted  with  satisfaction. 

Young  children  should  not  be  kept  at  the  same  study  or  in  the 
same  position  for  long  at  a  time.  The  exercises  should  be  frequently 
varied.  It  is  especially  with  children  in  the  primary  grades  that 
care  should  be  taken  not  to  overburden  their  minds  with  too  many 
hours  of  study,  or  too  long  continuance  at  the  same  exercise. 

Children  should  not  be  placed  in  a  regular  school  much,  if  at 
all,  before  the  completion  of  their  7th  year.  Between  the  ages  of  5 
and  7  they  may  be  sent  to  a  kindergarten.  From  7  to  9  years  they 
should  be  kept  at  their  studies  not  longer  than  three  hours  daily; 
from  9  to  13  years  four  hours  may  be  allotted  them;  and  from  12 
to  16  j^ears  they  may  be  kept  at  mental  work  five  to  six  hours  daily. 
This  does  not  mean  that  pupils  are  to  be  kept  continuously  at  their 
studies  during  these  hours,  but  that  they  should  be  neither  com- 
pelled nor  permitted  to  study  longer  than  these  periods  each  day. 
It  is  believed  that  these  figures  represent  the  capacity  for  endurance 
in  the  majority  of  children,  and  they  should  be  adopted  in  all  schools 
where  the  largest  return  in  mental  acquirements  is  desired  at  the  least 
expenditure  of  health.  Excess  of  time  expended  in  study  is  almost  cer- 
tainly followed  by  physical  deterioration.  "A  little  less  brain :  a  little 
more  muscle,"  for  our  children,  is  a  legitimate  demand  that  we 
may  make  of  legislators  and  school-boards. 

.  Gymnastic  exercises  should  form  part  of  the  daily  routine  in 
all  schools.  These  exercises  should  take  place,  when  practicable,  in  the 
open  air.  Playing,  romping,  laughing,  and  singing  should  be  en- 
couraged, rather  than  the  natural  tendency  to  boisterous  play  re- 
strained. It  is  especially  desirable  that  female  children  should  be 
encouraged  to  take  part  in  these  diversions.  The  desire,  on  the  part 
of  many  parents,  to  see  little  girls  deport  themselves  as  young  ladies, 
before  the  time  even  when  they  write  their  age  in  two  figures,  is 
very  reprehensible,  and  deserves  the  most  unqualified  condemnation. 
Moliere's  satirical  remark,  "II  n'y  a  plus  d'enfants,"^  seems  to  be 
.  literally  true  at  the  present  day. 

The  principal  diseases  incident  to  school-life  are  myopia,  spinal 
deformities,  nervous  and  digestive  disorders,  pulmonary  phthisis,  and 


*  There  are  no  more  children." 


236 


TEXT-BOOK  OF  HYGIENE. 


the  comnmnicable  diseases,  viz. :  chicken-pox,  small-pox,  erysipelas, 
measles,  rotheln,  scarlatina,  typhoid  fever,  and  contagious  ophthalmia. 
By  judicious  sanitary  measures  these  can  all  be  very  much  diminished 
and  some  entirely  prevented. 

It  has  been  shown  by  the  examination  of  the  eyes  of  school- 
children that  near-sightedness  increases  progressively  from  the  low- 
est to  the  highest  classes.  Children  who  enter  school  with  an  hered- 
itary tendency  to  myopia,  or  who  are,  perhaps,  already  near-sighted 


Fig.    30. — Myopia   According   to    School-classes — Boys. 

to  a  slight  degree,  soon  become  more  intensely  myopic;  while  others, 
who  may  be  even  hypermetropic  on  entering  school,  will  be  found 
to  have  become  near-sighted  during  school-life.  In  examinations  of 
over  30,000  pupils  of  grammar  and  high  schools  in  Germany,  Austria, 
Russia,  and  Switzerland,  it  has  been  found  that  the  average  pro- 
portion of  near-sightedness  is  a  fraction  over  40  per  cent.,  varying, 
in  the  different  classes,  from  22  per  cent,  for  the  lowest  to  58  per 
cent,  for  the  highest  classes.  These  figures  represent  the  averages 
of  all  the  examinations  made.     In  some  particular  schools,  for  ex- 


SCHOOL  HYGIENE. 


237 


ample  in  the  gymnasium  (high  school)  of  Erlangen,  the  percent- 
age in  the  higher  classes  was  88  per  cent.,  in  the  gymnasium  of 
Coburg,  86  per  cent.,  and  in  the  gymnasium  of  Heidelberg  the  pro- 
portion of  myopic  students  in  the  highest  class  is  said  to  have  reached 
100  per  cent,  in  1877.  In  the  primary  schools  the  percentage  was 
found  to  be  much  lower.  Eecent  investigations  in  the  schools  of 
Stockholm,  by  Widmark,  show  that  among  school-children  examined 
under  7  years  of  age  there  was  no  myopia.  In  the  higher  classes  the 
myopia  increases  not  only  in  degree,  but  in  frequency.  The  diagrams, 
Figs.  30  and  31,  show  graphically  the  increase  in  degree  and  f re- 


Fig.  31. — Myopia  According  to  School-classes — Girls. 

quency  of  myopia  in  the  several  school-classes.  These  observations 
show  that  the  number  of  myopic  individuals  bears  a  constant  relation 
to  the  intensity  of  use  of  the  visual  organs.  The  results  of  the  obser- 
vation of  different  observers  in  different  countries  also  uniformly  point 
to  the  conclusion  that  not  only  does  the  number  of  near-sighted 
pupils  increase  as  the  higher  classes  are  reached,  but  the  degree  of 
myopia  increases  likewise.  Thus,  a  pupil  who  may  have  only  a  mod- 
erate degree  of  m3^opia  on  entering  the  school  will  have  myopia  in  a 
higher  degree  as  he  advances  in  his  classes.  Erismann  found,  on  re- 
examining the  same  pupils  annually,  that  in  six  years  13.14  per  cent. 


238  TEXT-BOOK  OF  HYGIENE. 

of  those  examined  had  developed  myopia  from  emmetropia,  while  in 
24.57  per  cent,  of  near-sighted  pupils  the  degree  of  myopia  had  in- 
creased.^ 

The  principal  causes  of  the  prevalence  of  near-sightedness  in 
schools  are  badly-arranged  or  insufficient  light,  bad  air,  over-heating 
of  the  school-rooms,  improper  construction  of  desks  compelling 
children  to  lean  forward  while  reading  or  writing,  and  badly-printed 
text-books.  The  use  of  small  type,  poor  paper,  and  bad  press-work 
in  text-books  is  very  reprehensible.  The  type  technically  known  as 
Long  Primer  is  the  smallest  that  should  be  used  in  text-books.  That 
badly-arranged  light  and  improper  seats  are  causes  of  myopia  has 
been  shown  by  Forschutz  in  his  examinations  of  the  pupils  in  the 
public  schools  of  Coburg.  He  found  that  in  the  newer  schools,  in 
which  the  light  and  seats  are  better  arranged,  the  percentage  of  near- 
sight  decreased.  The  average  percentage  of  those  examined  in  1874 
was  21,  while  in  1877  it  had  been  reduced  to  15,*  showing  the  great 
improvement  due  to  the  application  of  correct  sanitary  principles  in 
the  construction  of  school-houses. 

Defective  hearing  has  recently  been  shown  to  be  especially  fre- 
quent among  school-children.  A  Berlin  aurist  found  1392  children 
out  of  5902  (23.6  per  cent.)  suffering  from  ear  disease  of  some  kind. 
Dr.  Samuel  Sexton,  of  New  York,  and  the  late  Dr.  Chas.  F.  Percivall, 
director  of  music  in  the  public  schools  of  Baltimore,  have  arrived 
at  similar  results  after  examination  of  a  large  number  of  school- 
children. 

Spinal  curvature  is  present  in  a  large  proportion  of  the  children 
attending  schools.  Statistics  are  not  very  full  upon  this  subject,  but 
one  author,  Guillaume,  states  that  he  found  lateral  curvature  of  the 
spine  in  218  out  of  731  school-children — a  proportion  of  29.5  per 
cent.  This,  of  course,  includes  the  slighter  degree  of  curvature, 
which  cannot  be  properly  termed  a  disease.  Among  30,000  Danish 
school-children  13  per  cent,  had  some  variety  or  degree  of  spinal 
deformity.  M.  Eulenburg,^  found  that  among  1000  persons  with 
lateral  curvature  of  the  spine,  the  disease  began  in  887  between  the 
ages  of  6  and  14;  that  is  to  say,  during  the  years  of  school-life. 
Girls  are  affected  more  than  ten  times  as  often  as  boys,  the  proportion 
being  93.43  per  cent,  in  the  former  and  only  6.57  per  cent,  in  the 
latter.  - 


'  Erismann.  Die  Hygiene  der  Sehule,  in  von  Pettenkofer  und  Ziemssen's 
Handbuch  der  Hygiene,  "ll  Th.,  2  Abth.,  p.  30. 

*  Quoted  by  Colin   in  Realencyclopfedie  d.   ges.   Heilk.,  Bd.   XII,   p.   263. 
"  Realencyclopaedie  d.  ges.  Heilk.,  Bd.  XI,  p.  564. 


SCHOOL  HYGIENE. 


239 


The  especial  causes  of  spinal  curvature  occurring  during  school- 
life  are  improperly-constructed  seats  and  desks  and  an  improper 
position  of  the  body.  Many  pupils  habitually  assume  a  "twisted" 
position,  which  is  very  liable  to  produce  spinal  distortion  in  children 
of  weak  muscular  development.  The  manner  in  which  a  desk  that  is 
too  high  for  the  pupil  may  produce  spinal  distortion  is  very  well 
shown  in  Fig.  32.  An  improper  position  is  more  likely  to  be  un- 
consciously assumed  by  girls  than  by  boys.  The  clothing  is  respon- 
sible for  this,  for  when  the  girl  files  into  her  place  behind  the  desk, 
her  clothing,  hanging  loosely  about  her,  is  swept  back  and  forms  a 


Fig.  32. 


-Showing  Influence  of  a  High  Desk  in  Causing  Spinal 
Curvature. 


pad,  upon  which  she  sits  with  one  buttock.  Another  cause  of  this  is 
a  habit  many  girls  have  of  sitting  on  one  foot.  The  greater  eleva- 
tion of  her  seat  on  that  side  throws  the  spinal  column  out  of  the 
vertical  line,  which  is  compensated  by  a  partial  twisting  of  the  trunk. 
The  attention  of  teachers  should  be  directed  to  this  faulty  habit, 
which  can  be  easily  corrected,  and  its  consequences  averted  by  timely 
interference. 

Nervous  disorders  are  comparatively  frequent  among  school- 
children. Headaches  are  often  due  to  insufficient  ventilation,  im- 
proper food,  bad  digestion,  and  excessive  mental  strain.  Defective 
light  may  also  be  the  cause  of  headaches  by  causing  ocular  fatigue. 


240  TEXT-BOOK  OF  HYGIENE. 

Disordered  menstruation  in  girls  is  a  frequent  cause  which  is 
not  to  be  overlooked.  Hysterical  and  imitative  affections  are  not  in- 
frequent, and  sometimes  pass  through  entire  schools,  including  even 
the  teachers.  Girls  are,  of  course,  more  subject  to  this  class  of  dis- 
orders than  boys,  but  the  latter  are  not  entirely  exempt. 

Chorea  is  one  of  the  nervous  disorders  which  should  debar  the 
child  who  has  it  from  school,  not  only  on  the  child's  own  account, 
but  also  because  the  trouble  may  be  transmitted  to  other  children 
through  association  and  imitation. 

Derangements  of  the  digestive  organs  are  exceedingly  frequent 
among  school-children.  They  can  generally  be  traced  to  the  use  of 
improper  food.  The  eating  of  cold  lunches  should  be  discouraged  as 
much  as  possible. 

Nuts,  candies,  pies,  fruit-cakes,  bananas,  and  above  all,  pickles 
are  most  fruitful  sources  of  digestive  derangements  of  children.  The 
absence  of  proper  accommodations  to  enable  children — especially 
girls — to  answer  the  demands  of  nature  are  frequent  sources  of  diges- 
tive and  nervous  disorders. 

The  seeds  of  pulmonary  consumption  are  frequently  implanted 
during  school-life.  A  neglected  cough;  bad  ventilation,  under  which 
term  may  be  comprised  overheating  and  cold  draughts,  as  well  as 
polluted  air;  improper  position  of  the  body,  excessive  mental  work, 
underfeeding,  and  the  failure  to  exclude  children  who  are  the  sub- 
jects of  tuberculosis,  may,  any  of  them,  be  the  starting-point  of  this 
fatal  disease. 

Especial  care  should  be  taken  to  prevent  the  introduction  or 
dissemination  of  communicable  diseases  through  schools.  The  im- 
portance of  this  duty  should  be  at  all  times  impressed  upon  school- 
boards  and  teachers.  In  the  first  place,  no  child  should  be  admitted 
within  the  door  of  the  school-room  unless  it  first  presents  undoubted 
evidence  of  protection  against  small-pox,  either  by  having  passed 
through  a  previous  attack  or  by  a  proper  vaccination.  In  case  of  an 
actual  or  threatened  epidemic  of  small-pox  the  entire  school,  including 
teachers,  should  be  vaccinated. 

Children  should  not  be  admitted  to  school  coming  from  a  house 
where  there  is  at  the  time,  or  has  recently  been,  a  case  of  communi- 
cable disease,  such  as  small-pox,  diphtheria,  scarlet  fever,  or  measles. 
They  should  be  excluded  in  each  case  for  a  period  of  time  equivalent 
to  the  incubation  of  the  given  disease.  It  goes  without  saying  that 
no  child  having  itself  been  sick  with  a  communicable  disease  should  be 
admitted  to  school  until  entirely  restored  to  health. 


SCHOOL  HYGIENE. 


241 


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242 


TEXT-BOOK  OF  HYGIENE. 


Table  XXXI. 

Whilelegge's  Table. 


Diseases 

Earliest  Date  of  Return  to  School  After 
an  Attack. 

Small-pox   

18  days 
18  days 

14  days 
12  days 
16  days 
16  days 

21  days 

24  days 

When  all  scabs  have  fallen  off. 

Chicken-pox 

Scarlet  fever 

When  all  scabs  have  fallen  off. 
^  Six  weeks,  and  then  only  if  no  des- 

Diphtheria 

(      quamation  or  sore  throat. 

S  Three  weeks,  if  convalescence  is  com- 

Measles 

(      plete,  and  no  bacilli  remain. 

S  Three  weeks,  if  all  desquamation  and 

\      cough  have  ceased. 

^  Two  to  three  weel;s,  according  to  the 

German  Measles 

Whooping  Cough 

(      nature  of  the  case. 

C  Six  Aveeks  from  the  commencement  of 
the  whooping,  if  the  characteristic 

\      spasmodic  cough  and  whooping  have 
ceased.      Earlier,    if   all   cough  be 
gone. 
Four  weeks,  if  all  swelling  has  sub- 
sided. 

Mumps 

School  quarantine  should  be  established  for  the  following  dis- 
eases: In  small-pox  and  chicken-pox,  until  every  scab  has  fallen. 
In  whooping  cough,  until  the  spasmodic  cough  and  characteristic 
whoop  have  ceased.  In  diphtheria,  for  at  least  three  weeks,  but  in 
every  case  until  a  bacteriological  examination  of  nose  and  throat  proves 
that  none  of  the  specific  organisms  are  present,  and  there  must  also 
be  no  discharge  from  the  nose,  throat,  ears,  or  eyes,  and  no  album- 
inuria. In  scarlet  fever,  for  six  weeks  from  the  time  the  rash  appears, 
provided  also  that  desquamation  and  cough  have  ceased.  In  measles, 
until  desquamation  is  complete.  In  contagious  ophthalmia,  until 
complete  recovery  of  the  patient.  In  every  case  there  must  be  thorough 
and  efficient  disinfection  of  the  home,  clothing  and  person  of  the  child 
before  he  returns  to  school. 

When  a  case  of  contagious  disease  has  accidentally  obtained  en- 
trance to  the  school,  the  pupils  should  be  dismissed  for  the  day,  and 
the  room  thoroughly  disinfected  by  means  of  formaldehyde. 

Teachers  are  not  infrequently  guilty  of  the  grave  imprudence  of 
sending  pupils  from  the  school  to  the  house  of  an  absent  child  to 
inquire  the  reason  of  the  latter's  non-appearance  at  scliool.     It  fre- 


SCHOOL  HYGIENE.  243 

quently  happens  that  the  absent  child  is  sick,  and  the  messenger  is 
invited  to  the  sick-room  to  see  his  or  her  class-mate.  There  can  be 
no  room  for  doubt  that  scarlet  fever,  diphtheria,  and  measles  have 
often  been  introduced  into  schools  in  consequence  of  such  thoughtless- 
ness on  the  part  of  teachers. 

All  schools  should  be  inspected  daily  by  a  physician  appointed  for 
the  purpose. 

In  order  to  promote  the  proper  hygienic  management  of  schools, 
all  teachers  should  be  required  to  submit  to  an  examination  in  the 
principles  and  practice  of  hygiene,  at  least  so  far  as  school  hygiene 
especially  is  concerned.  This  is  a  demand  that  school-boards  could 
reasonably  insist  upon,  and  there  can  be  no  question  that  the  improve- 
ment in  the  health  of  the  pupils  would  amply  justify  it. 

In  all  boarding-schools  there  should  be  an  infirmary,  properly 
equipped  for  isolating  cases  of  communicable  disease.  This  infirmary 
should  preferably  be  located  in  the  upper  story  of  the  building,  or  in 
an  isolated  wing. 

A  phase  of  school  life  which  is  seldom  discussed  and  generally 
tabooed  is  the  sexual  development  of  the  pupils.  There  is  no  doubt 
that  vicious  sexual  habits  are  often  acquired  at  schools,  more  espe- 
cially boarding  schools  and  dormitories.  It  should  be  incumbent 
upon  teachers  to  keep  a  watchful  eye  on  this  phase  of  school  life  with 
a  view  of  detecting  vicious  practices.  The  course  on  school  physiology 
should  include  the  study  of  sexual  development  in  plants  and  the 
lower  animals;  while  among  the  older  pupils  the  results  of  sexual 
abuses  and  venereal  diseases  may  be  properly  discussed. 


QUESTIONS  TO  CHAPTER  VIII. 

SCHOOLS. 

What  does  the  hygiene  of  schools  comprise?  What  principles  are  ap- 
plicable in  the  construction  of  school-houses?  What  is  to  be  sought,  and 
what  avoided,  in  the  selection  of  a  site? 

What  should  be  the  limit  of  height  for  school-houses?  What  rooms  are 
needed  besides  those  for  study  or  recitation?  What  precautions  must  be 
observed  regarding  stairs,  railings,  and  doorways?  How  may  the  ground-air 
be  kept  out  of  the  building?  What  kinds  of  floors  should  the  various  rooms 
have  ? 

What  will  be  probably  the  best  means  of  heating  a  school-house  ?  What 
is  the  usual  method  in  large  schools?  Which  will  usually  give  the  best  ven- 
tilation, natural  or  artificial?  When  and  how  may  school -rooms  be  ventilated 
to  advantage? 

How  large  should  an  ordinary  school-room  be?  WTiat  are  the  advan- 
tages of  a  room  of  this  size?  How  many  pupils  would  this  accommodate,  and 
about  how  much  air-space  would  each  have?     Is  this  sufficient? 

On  which  side  of  the  room  should  the  windows  be,  if  possible?  How 
should  the  seats  and  desks  be  arranged  in  relation  to  the  windows?  What 
should  be  the  relation  of  window-area  to  floor-area  ?  How  high  should  the 
windows  be  above  the  floor,  and  how  near  to  the  ceiling  should  they  reach? 
Wliat  are  the  objections  to  windows  on  two  sides  of  the  room?  Will  windows 
of  the  above  dimensions  properly  illuminate  the  room?  How  much  artificial 
light  will  be  needed  for  proper  illumination?  What  should  be  the  color  of 
walls  and  ceilings? 

Where  should  the  water-closets,  etc.,  of  a  school  be  located?  What 
supervision  of  these  must  be  exercised? 

How  high  should  school-seats  be?  What  should  be  the  relation  of  seat 
to  desk,  and  how  high  should  the  latter  be?  Why  should  the  front  edge  of 
the  seat  be  brought  under  the  desk? 

How  far  should  the  black-boards  be  from  the  pupils?  On  which  side 
of  the  room?     How  should  the  surface  be  finished? 

When  should  a  child  begin  to  go  to  school?  What  is  the  maximum 
time  advisable  for  daily  study  at  the  respective  ages?  What  should  be  the 
length  of  lessons  and  recitations  for  each  age?  What  is  an  almost  certain 
result  of  too  long  study-hours?     What  should  form  part  of  the  daily  school- 

(244) 


QUESTIONS  TO  CHAPTER  VIII.  245 

routine?     Should  this  be  taken  from  the  recess  period,  or  should  it  be  part 
of  the  school-work? 

What  are  some  of  the  diseases  incident  to  school-life?  Can  these  be 
prevented?  Are  they  altogether  due  to  school-life?  How  does  the  proportion 
of  cases  of  near-sightedness  vary  in  school-children?  Is  the  increase  one  of 
degree  or  of  frequency?  What  are  the  causes  of  this  excess  of  myopia?  If 
these  causes  c.re  avoided  or  corrected,  will  the  prevalence  of  myopia  decrease? 

What  other  sense  is  defective  among  school-children?  What  physical 
deformity  is  very  prevalent?  What  are  the  special  causes  of  this  deformity? 
Why  is  it  apt  to  be  more  common  among  girls  ?  At  what  age  is  the  deformity 
most  apt  to  begin? 

What  nervous  disorders  are  frequent  among  school-children?  What  are 
some  of  the  causes  of  chronic  headache?  What  pupils  are  most  subject  to 
hysterical  affections?  What  are  some  causes  of  nervous  disorders?  Of  diges- 
tive disturbances? 

How  may  consumption  or  other  forms  of  tuberculosis  be  due  to  the 
school-life?  What  precautions  should  be  observed  in  regard  to  the  prevention 
of  the  spread  of  infectious  diseases  among  school-children?  What  diseases  are 
to  be  especially  guarded  against,  and  how  shall  this  be  done?  WTiat  should 
be  the  shortest  limit  of  quarantine  against  a  pupil  that  has  had  any  one  of 
these  diseases  ?  If  a  case  of  infectious  disease  gains  entrance  to  the  school, 
what  is  to  be  done?  Why  should  teachers  be  required  to  pass  an  examination 
on  the  principles  of  hygiene? 


CHAPTER  IX. 

INDUSTRIAL   HYGIENE. 

One  of  the  most  interesting  chapters  in  the  study  of  hygiene 
is  that  which  treats  of  the  relations  of  occupations  to  health  and 
life.  ^Yhile  it  is  unquestionable  that  certain  occupations  are  intrins- 
ically dangerous  to  health,  there  can  be  no  doubt  that  in  many  in- 
stances incidental  conditions  not  necessarily  connected  with  the  occu- 
pation are  factors  in  the  production  of  disease.  Such  factors  are  bad 
ventilation  and  other  insanitary  surroundings,  as  well  as  in  many 
cases  want  of  sufficient  or  proper  food. 

Occupations  induce  disease  by  compelling  the  workmen  to  inhale 
irritating,  poisonous,  or  offensive  gases,  vapors,  or  dust;  or  by  caus- 
ing the  absorption  through  the  skin  or  mucous  membranes  of  irritat- 
ing or  poisonous  substances.  Changes  of  temperatiire,  as  exposure  to 
great  heat  or  cold,  produce  diseases  which  are,  in  some  instances,  char- 
acteristic. In  another  class  of  cases  the  excessive  use  of  certain  organs, 
as  the  nervous  system,  the  eyes,  the  vocal  organs,  or  various  groups  of 
muscles,  produce  characteristic  morbid  effects.  Again,  a  constrained 
attitude  while  at  work,  a  sedentary  life,  or  occupations  involving  ex- 
posure to  mechanical  violence  are  recognized  sources  of  disease  and 
death. 

The  table  on  page  247  gives  the  mortality  and  average  age  at 
death  of  all  decedents  over  20  years  of  age  whose  occupation  was 
specified,  in  the  State  of  Massachusetts,  for  thirty-one  years  and  eight 
months.  The  total  number  of  decedents  was  144,954;  the  average 
age  at  death,  50.90  5^ears.  Subdivided  into  classes  and  individual 
occupations,  the  results  are  given  in  Table  XXXII. 

The  latter  table  cannot  be  absolutely  relied  upon  for  several 
reasons,  the  principal  of  which  is  that  the  table  is  incomplete.  Many 
of  the  occupations  are  merely  temporary,  and  persons  are  constantly 
shifting  from  the  pursuit  of  one  calling  to  another.  Judges  and 
law3'^ers,  for  example,  should  be  included  under  one  heading,  while 
the  class  "students"  should  be  excluded  altogether.  The  table  shows, 
however,  very  clearly,  the  relations  of  certain  occupations  to  longevity. 
It  is  seen,  for  example,  that  agriculturists  have  the  greatest  expecta- 
tion of  life.  Next  to  these  come  mechanics  engaged  out-of-doors. 
Professional  men  come  next,  and  of  these  clergymen  and  members  of 
X246) 


INDUSTRIAL  HYGIENE. 


247 


Table  XXXII. 

Occupations  of  Persons  whose  Occupations  were  specified,  and  whose  Deaths  were 
registered  in  Massachusetts  during  a  period  of  thirty-one  years  and  eight 
months,  ending  with  December  31,  1874.  ^ 


Occupations. 


Class  I.  Cultivators  of 
the  Earth:  Faruiers, 
Gardeners,  etc.  .    .    . 


Class  II.  Active  Me- 
chanics Abroad .  .  . 
Brick-makers  .  .  .  . 
Carpenters  and  Joiners 
Caulkers  and  Gravers 

Masons 

Millwrights 

Riggers 

Ship-carpenters     .    ,    . 

Slaters  

Stone-cutters 

Tanners 

Class  III.  Active  Me- 
chanics in  Shops  .    . 

Bakers 

Blacksmiths 

Brewers 

Cabinet-makers    .    .    . 

Calico-printers  .... 

Card-makers 

Carriage  -  makers  and 
Trimmers 

Chair-makers     .... 

Clothiers     

Confectioners    .... 

Cooks  

Coopers 

Coppersmiths    .... 

Curriers 

Cutlers 

Distillers 

Dyei-s 

Founders 

Furnace-men    .... 

Glass-blowers    .... 

Gunsmiths 

Hatters 

Leather-dressers  .    .    . 

Macliinists      

Millers 

Musical-Inst.  mkrs. 


Number 

Average 

of 

Age  at 

Persons. 

Death. 

31,833 

65.29 

10,893 

56.19 

106 

46.85 

6,150 

53.33 

180 

58.59 

1,662 

50.33 

118 

59.14 

161 

52.25 

873 

58.58 

81 

40.99 

1,025 

40.90 

537 

50.36 

16,576 

47.57 

471 

47.04  ! 

2,402 

53.26 

28 

47.11 

781 

48.84 

9 

52.11 

39 

48.23 

276 

48.21 

138 

41.77 

84 

56.50 

85 

44.11 

112 

40.82 

927 

59.22 

101 

45.89 

366 

41.50 

131 

89.21 

27 

56.85 

143 

45.17 

361 

42.51 

133 

48.42 

132 

37.88 

250 

48.86 

3.36 

54.67 

179 

47.23 

2,097 

41.67 

278 

57.14 

33 

46.73 

OcrUPATIONS. 


Nail-makers     .    .    .    . 

Pail-  and  Tub-  makers 

Painters 

Paper-makers  .    .    . 

Piano-forte-makers 

Plumbers 

Potters 

Pump-  and  Block 
makers    .    . 

Reed-makers 

Rope-makers 

Tallow-chandlers 

Tinsmiths 

Trunk-makers 

Upholsterers 

Weavers    .    . 

Wheelwrights 

Wood-turners 

Mechanics  (not  speci- 
fied)  

Class  IV.  Inactive 
Mechanics  in  Shops 

Barbers  

Basket-makers    .    .    . 

Book-binders  .... 

Brush -makers      .    .    . 

Carvers  .... 

Cigar-makers   .    . 

Clock  -  and  watch- 
makers   

Comb-makers  .... 

Engravers 

Glass-cutters    .    .    .    . 

Harness-makers  .    .    . 

Jewelers 

Operatives 

Printers 

Sail-makers 

Shoe- cutters     ... 

Shoe-makers    ... 

Silver  or  Gold  smiths 

Tailors 

Tobacconists    .... 

Whip-makers  .... 

Wool-sorters    ,    ,    ,    , 


Number 

of 
Persons. 


174 

5 

1,850 

288 

111 

131 

40 

89 

9 

248 

67 
375 

48 
124 
480 
507 

76 

2,015 


17,233 

403 
70 

150 
53 
90 

154 

100 
134 
124 

76 
423 
468 
3,138 
717 
217 
3'33 
9,772 

92 
1,393 

43 

99 
155 


Average 
Age  at 
Death. 


41.49 
36.60 
45.07 
48.29 
43.38 
35.58 
56.67 

54.79 

42.78 
58.05 
54.93 
41.05 
39.60 
38.83 
44.95 
56.98 
52.07 

44.84 


43.87 
89.81 
61.63 
40.13 
43.11 
34.00 
38.36 

53.86 
51.88 
40.88 
43.16 
48.74 
40.34 
39.16 
38.63 
53.21 
42.94 
44.61 
46.13 
47  34 
50.35 
42.63 
48.09 


*  Thirty-third  Registration  Report  of  Massachusetts,   p.   cvi   et  seq. 


248 


TEXT-BOOK  OF  HYGIENE. 


Table  XXXII   (Continued). 


OCCTTPATIONS. 


Class  V.  Laborers  (no 
special  trades)  .    .    . 

Laborers      

Servants  

Stevedores 

Watchmen 

Workmen  in  Powder- 
mills     

Class    V I .      Factors 

Laboring  Abroad,  etc. 

Baggage-masters  .    .    . 

Brakemen       

Butchers 

Chimney-sweeps  .    .    . 

Drivers 

Drovers 

Engin'rs  and  Firemen 

Expressmen 

Ferrymen 

Lightliouse-keepers 

Peddlers 

Sextons    . 

Soldiers 

Stablers  

Teamsters 

Weighers  and  Gangers 
Wharfingers  ..... 

Class  VII.     Employed 
on  the  Ocean  .... 

Fishermen  ..... 

Marines       ...... 

Naval  OflBcers  .... 

Pilots 

Seamen 

Class  VIII.  Merch'ts, 
Financ'rs,  Ag'is,  etc. 

Agents 

Bankers 

Bank  Officers     .... 

Boarding-House  kprs. 

Book-sellers 

Brokers 

Clerks  and  Book-kprs. 

Druggists  and  Apoth- 
ecaries      


Number 

of 
Persons. 


28,058 
27,383 

389 
76 

193 

18 


7,035 

37 

246 

537 

4 

327 

17 

567 

216 

9 

10 

417 

81 

2,885 

354 

1,282 

24 

22 


8,844 

433 

4 

58 

82 

8.267 


15,977 

376 

49 

151 

75 

73 

198 

3,435 

255 


Average 
Age  at 
Death. 


47.41 
47.49 
40.10 
52.09 
50.06 

39.67 

36.29 
34.08 
26.44 
50.19 
34.50 
38.88 
49.29 
38.77 
41.30 
53.78 
60.40 
45.18 
59  94 
28  37 
42.54 
40.35 
60.67 
50.00 


46.44 
42.82 
41.25 
50.00 
60.38 
46.45 


48.95 
46.76 
57.61 
55.14 
47.96 
53.05 
49.58 
35.93 

42.37 


OCCUPATIOlSfS. 


Gentlemen 

Grocers      

Innkeepers 

Manufacturers     .    .    . 

Merchants 

News-dlrs.  and  Car'i-s 

R.  R.  Agents  or  Con- 
ductors     .... 

Saloon-    and  Restau 
rant-  keepers    .    . 

Stove-dealers   .    .    . 

Telegraphers    .    .    . 

Traders      


Class    IX .      Profes 

sional  Men  . 
Architects  .  . 
Artists  .... 
Civil  Engineers 
Clergymen  .  . 
Comedians  .  . 
Dentists  .  .  . 
Editors  and  Reprtrs 
Judges  and  Justices 

Lawyers 

Musicians  .... 
Photographers  ;  . 
Physicians  .... 
Professors  .... 
Public  Officers  .  . 
Sheriffs,     Constables, 

and  Policemen 
Students  .... 
Surveyors  .  .  . 
Teachers   .... 


Class  X.     Females 
Domestics     . 
Dress-makers 
Milliners   .    . 
Nurses   . 
Operatives    . 
Seamstresses 
Shoe -binders 
Straw-workers 
Tailoresses    . 
Teachers   .    . 
Telegraphers 


Number 

of 
Persons. 


1,512 

517 

467 

1,375 

3,927 

27 

318 

299 

12 

5 

2,908 

5,175 
29 

186 
117 
965 

32 
114 

87 

18 
676 
266 

10 
1,166 

45 
437 

158 

288 

86 

495 

3,343 

1,037 

259 

136 

116 

703 

289 

48 

73 

233 

442 

7 


Average 
Age  at 
Death . 


68.42 
47.59 
50.04 
51.23 
54.17 
41.22 

39.85 

40.90 

45.25 
28.80 
48.08 

50.81 
47.07 
44.18 
43,32 
58  57 
37  31 
41.61 
46.68 
64.11 
56.45 
41.59 
36.80 
54.99 
55.93 
55.37 

53.76 
23.23 
51.44 
41  79 

39.13 
46  64 
43.36 
39.42 
61.06 
27.82 
46.50 
43.12 
34  83 
47.49 
31.27 
24.43 


the  bar  have  the  first  and  second  places  respectively.  The  expec- 
tation of  life  of  physicians  is  above  the  average,  being  nearly  55 
years.  Mechanics   engaged   in   active   work   in-doors   may   expect  to 


OCCUPATIONS  PREJUDICIAL  TO  HEALTH.  249 

live  3.70  years  longer  than  those  whose  occupation  requires  them  to 
retain  a  more  or  less  constant  position. 

Occupations  which  are  accompanied  by  the  formation  of  much 
dust,  either  inorganic  or  organic,  are  especially  unfavorable.  They 
usually  produce  disease  of  the  respiratory  organs,  which  may  eventu- 
ate in  phthisis.  In  the  table  it  is  seen  that  the  average -age  at  death 
of  stone-cutters  was  40.90;  of  cotton-factory  operatives — male,  39.16; 
female,  21.S2f  of  cigar-makers,  38.36;  and  of  cutlers,  39.21  years.^ 
These  figures  more  or  less  closely  approximate  the  conditions  which 
have  been  shown  to  exist  in  England  and  on  the  Continent  of  Europe, 
In  Sheffield,  the  workmen  who  grind  and  polish  cutlery,  called  "dry 
grinders,"  are  said  to  suffer  from  a  characteristic  pulmonary  affection 
termed  "grinders'  asthma"  (emphysema)  in  the  proportion  of  69 
per  cent,  of  the  whole  number  employed.  The  average  duration  of 
life  of  the  needle-grinders  of  Derbyshire  is  30.66  years.  Among  the 
cutlery-grinders  of  Solingen,  in  Rhenish  Prussia,  Oldendorff  found 
29  per  cent,  suffering  from  pulmonary  affections,  while  the  average 
age  at  death  of  the  "dry  grinders"  was  40,7  years. 

OCCUPATIONS  PREJUDICIAL  TO  HEALTH. 

The  diseases  of  occupations  may  conveniently  be  divided  into  the 
following  classes : — 

1.  Diseases  due  to  the  inhalation  of  irritating  or  poisonous 
gases  and  vapors. 

2.  Diseases  due  to  the  inhalation  of  irritating  or  poisonous  dust. 

3.  Diseases  due  to  the  absorption  or  local  action  of  irritating  or 
poisonous  substances. 

4.  Diseases  due  to  exposure  to  elevated  or  variable  temperature 
or  atmospheric  pressure. 

5.  Diseases  due  to  excessive  use  of  certain  organs. 

6.  Diseases  due  to  a  constrained  attitude  and  sedentary  life. 

7.  Diseases  from  exposure  to  mechanical  violence, 

^  These  figures  must  be  accepted  with  much  reserve.  While  it  is  prob- 
able that  the  average  age  at  death  among  women  engaged  in  different  occupa- 
tions is  less  than  that  of  men  engaged  in  the  same  occupations,  the  figures  in 
Table  XX,  Class  X,  cannot  be  used  as  a  basis  of  comparison.  So  many  vi'omen 
are  annually  withdrawn  from  the  various  occupations  by  marriage,  which 
places  them  under  different  conditions,  that  the  statistics  of  the  occupations 
of  women  in  the  table  are  untrustworthy. 


250  TEXT-BOOK  OF  HYGIENE. 

I.  DISEASES  DUE  TO  THE  INHALATION  OF  IRRITATING  OR 
POISONOUS  GASES  OR  VAPORS. 

Sulphurous-acid  gas  is  used  in  various  trades  as  a  bleaching 
agent.  In  the  manufacture  of  straw  hats  and  in  the  drying  or  "pro- 
cessing" of  hops  this  agent  is  extensively  employed,  and  the  people 
engaged  in  these  industries  frequently  suffer  from  respiratory  and 
digestive  disorders.  These  are,  however,  rarely  serious.  If  free  ac- 
cess of  air  is  allowed,  the  dangers  to  health  in  the  above  employments 
are  very  slight. 

Nitric-acid  fumes  may  be  dangerous  to  health  when  inhaled  in 
a  concentrated  form,  but  very  few  cases  are  on  record  where  any 
positively  deleterious  influence  can  be  traced  to  this  agent. 

Hydrocliloric-acid  fumes  may  prove  deleterious  to  the  workmen 
in  soda  manufactories,  where  the  fumes  are  disengaged  during  the 
so-called  "sulphate  process."  But  the  danger  is  probably  slight.  On 
the  other  hand,  attention  has  recently  been  called  to  a  peculiar  effect 
of  hydrochloric-acid  fumes  upon  the  workmen  in  fruit-canning  es- 
tablishments. The  men  who  seal  or  "cap"  the  cans  after  being  filled 
are  the  ones  affected.  The  lesion  has  been  described  by  Dr.  W. 
Stump  Forwood,  who  says  concerning  it :  "The  constant  inhalation 
of  the  fumes  of  muriatic  acid,  associated  as  they  are  with  the  lead 
solder,  which  the  busy  "capper"  neglects  to  protect  himself  against, 
soon  produces  inflammation  of  the  mucous  membrane  of  the  nose, 
which  finally  results  in  ulceration.  With  some  patients,  after  the 
removal  of  the  cause  and  the  application  of  proper  treatment,  recov- 
ery takes  place  after  two  or  three  months;  but  with  those  who  have 
a  scrofulous  taint  in  their  constitutions  this  ulceration  is  exceed- 
ingly intractable,  and,  in  spite  of  all  treatment,  proceeds  for  months 
and  even  years,  until  the  septum  is  finally  perforated.  And,  strange 
to  sa}^  it  is  the  common  experience  of  those  who  have  suffered  that, 
as  soon  as  perforation  takes  place,  all  the  soreness  and  consequent 
annoyance  disappears  and  the  patient  recovers,  with,  of  course,  a 
permanent  opening  in  the  nasal  septum."^  Dr.  Forwood  adds  that 
anointing  the  nose,  both  within  and  without,  several  times  a  day,  and 
avoidance  of  the  acid  fumes  as  much  as  possible,  will  prevent  the 
peculiar  affection. 

Ammonia  rarely  causes  disturbance  of  health  in  workmen 
brought  into  contact  with  it.  When  present  in  the  air  in  large  pro- 
portion it  may  give  rise  to  serious  symptoms.     As  it  is  often  used  to 

^Phila.  Med.  and  Surgical  Keporter,  June  30,  1883. 


DISEASES  DUE  TO  INHALATION  OF  GASES  OR  VAPORS.       251 

prevent  the  poisonous  effects  of  mercury  {q.  v.).  care  should  be  taken 
that  the  proportion  of  the  vapor  in  the  air  of  the  work-room  should 
not  exceed  5  per  cent. 

Chlorine  gas  is  very  deleterious  in  its  effects  upon  the  workmen 
brought  in  contact  with  it  in  the  various  industries  in  which  it  is 
employed,  Nearly  one-half  of  the  workmen  engaged  in  the  manufac- 
ture of  chlorinated  lime  and  in  bleaching  become  affected. 

The  respiratory  organs  are  principally  attacked.  Pneumonia  is 
exceptionally  frequent.  If  an  affected  individual  is  predisposed  to 
consumption  the  latter  disease  is  soon  lighted  up,  and  quickly  proves 
fatal.  The  effect  of  the  inhalation  of  concentrated  chlorine  is  thus 
graphically  described  by  Hirt*:  "The  workman  suffers  from  violent 
cough  and  extreme  dyspnoea.  In  spite  of  the  aid  of  the  auxiliary 
respiratory  muscles,  the  entrance  of  air  to  the  lungs  is  insufficient,  and 
the  widely-opened  eyes,  the  pale-bluish  color,  and  the  cold  perspiration 
plainly  show  the  mortal  agony  of  the  patient.  With  this  the  pulse 
is  small,  the  temperature  decreased.  Soon  after  removal  from  the  im- 
pregnated atmosphere  these  phenomena  disappear,  and  a  few  hours 
later  the  workman  is  found  enveloped  in  chlorine  and  hydrochloric- 
acid  vapors  in  his  accustomed  place  in  the  factory.  The  attacks  seem 
to  be  but  rarely  fatal." 

The  constant  inhalation  of  an  atmosphere  strongly  impregnated 
with  chlorine  produces  a  cachectic  appearance,  bronchial  catarrh,  loss 
of  the  sense  of  smell,  and  a  prematurely  aged  appearance.  When  this 
stage  of  chronic  chlorine  poisoning  has  been  reached  complete  health 
can  rarely  be  re-established,  even  if  the  patients  be  entirely  removed 
from  the  irritating  atmosphere. 

Carbon  monoxide  is  often  present  in  the  air  of  gas-works,  iron 
smelting-works,  and  coke  or  charcoal  furnaces.  The  workmen  en- 
gaged in  these  industries  often  suffer  with  diseases  of  the  respiratory 
organs,  digestive  disturbances,  and  general  debility.  Acute  poison- 
ing from  carbon  monoxide  is  relatively  frequent,  as  already  pointed 
out.^  The  prominent  symptoms  are  at  first  violent  headache,  dizziness, 
and  roaring  in  the  ears.  These  symptoms  are  followed  by  great 
depression  of  muscular  power,  nausea,  and  vomiting.  The  vomited 
matters  sometimes  gain  entrance  into  the  trachea,  and  may  thus  pro- 
duce strangulation.  Uncopsciousness,  convulsions,  and  asphyxia 
rapidly  succeed.     Paralyses  of  the  sphincters  and  of  groups  of  other 


••Von  Pettenkofer  und  Ziemssen's  Handbuch  der  Hygiene,  etc.,  II  Th., 
4  Abth.,  p.  30.  . 

"^  See  Chapter  I,  p.  26. 


252  TEXT-BOOK  OF  HYGIENE. 

muscles  are  often  present.  The  pulse  is  at  first  somewhat  increased, 
but  soon  becomes  slower.  The  respiration  is  slow  and  stertorous,  and 
the  temperature  falls  from  2.5°  to  3°  C.  (3°  to  4°  F.).  Glycosuria 
often  occurs.  If  death  does  not  occur  in  the  attack,  the  patient  fre- 
quently suffers  from  great  depression,  both  physical  and  mental;  loss 
of  appetite,  constipation,  and  various  paretic  conditions. 

The  slow  or  chronic  form  of  poisoning  by  carbon  monoxide  is 
characterized  by  headache,  dizziness,  slow  pulse  and  respiration,  nau- 
sea, and  sometimes  vomiting  and  purging.  Loss  of  memory  and 
diminution  of  mental  activity  are  also  said  to  be  effects  of  the  con- 
tinued inhalation  of  air  charged  with  carbon  monoxide. 

Carljon  dioxide  is  found  as  one  of  the  constituents  of  the  "choke- 
damp"  in  mines.  There  is  reason  to  believe  that  this  is  often  the 
source  of  ill  health  and  death  in  miners,  even  where  the  symptoms  of 
acute  carbon-dioxide  poisoning  are  not  present.  Hon.  Andrew  Eoy^ 
says  that  "it  is  more  insidious  than  direct  in  its  operations,  gradually 
undermining  the  constitution  and  killing  the  men  by  inches."  Diffi- 
culty of  respiration  and  wealoiess  are  the  only  symptoms  calling 
attention  to  the  pernicious  effects  of  the  gas.  \Yhere,  however,  the 
proportion  of  carbon  dioxide  is  large,  acute  poisoning  occurs.  This  is 
manifested  by  the  following  symptoms :  Loss  of  consciousness  and  of 
the  power  of  voluntary  motion.  In  some  cases  there  are  convulsions; 
in  others  the  above  s}Tuptoms  are  preceded  by  difficult  respiration, 
headache,  depression,  drowsiness,  or  psj'chical  excitement.  Recovery 
usually  soon  follows  after  removing  the  patient  into  a  purer  atmos- 
phere. 

Vintners,  distillers,  brewers,  and  yeast-makers  are  said  to  suffer 
from  the  effects  of  carbon  dioxide  occasionally,  but  serious  results 
from  this  cause  are  probably  very  infrequent. 

It  may  not  be  amiss  to  call  attention  here  to  another  dangerous 
mixture  of  gases  sometimes  found  in  mines,  and  which  is  occasionally 
the  source  of  appalling  accidents.  This  is  the  so-called  "fire-damp" 
or  light  carburetted  hydrogen  (CH^).  When  this  gas  is  mixed 
with  atmospheric  air  in  the  proportion  of  6  to  10  volumes  per  cent., 
the  mixture  becomes  violently  explosive  if  ignited.  The  danger  does 
not  cease  with  the  explosion,  however,  for  in  this  act  the  free  oxygen 
present  is  consumed  in  the  formation  of  carbon  dioxide,  and  the 
workmen  then  die  asphyxiated,  or  from  the  effects  of  "choke-damp." 
The  dangers  from  "fire-damp"  can  be  largely  averted  by  thorough  ven- 


°  Third  Annual  Report  State  Mine  Inspector  of  Ohio.     Quoted  in  Buck's 
Hygiene  and  Public  Health,  vol.  ii,  p.  243, 


DISEASES  DUE  TO  INHALATION  OF  GASES  OR  VAPORS.       253 

tilation  and  by  the  use  of  the  safety-lamp  of  Sir  Humphrey  Davy, 
which  gives  warning  of  the  presence  of  the  gas  and  permits  the  work- 
men to  escape  before  the  explosion  takes  place. 

Sulphuretted  hydrogen,  when  present  in  the  air  in  large  propor- 
tion— as,  for  example,  in  privy-vaults,  cess-pools,  and  sewers — may 
produce  serious  or  fatal  poisoning.  Formerly,  when  vaults  were 
cleaned  in  the  primitive  way,  these  accidents  were  frequent;  but  at 
the  present  day,  owing  to  improved  methods  of  removing  excreta, 
they  are  comparatively  rare.  The  precautions  advised  in  a  preceding 
chapter^  should  be  borne  in  mind  when  it  is  necessary  for  workmen 
to  enter  such  places. 

The  gases  resulting  from  the  putrid  decomposition  of  organic 
substances,  such  as  are  found  in  tanneries,  glue-  and  soap-works,  and 
similar  industries,  are  popularly  believed  to  give  rise  to  various  dis- 
eases. There  are  no  observations  on  record,  however,  to  show  that  such 
is  the  case.  As  a  matter  of  fact,  the  workmen  engaged  in  the  in- 
dustries mentioned,  seem  to  be  exceptionally  healthy,  and  to  resist 
to  a  considerable  degree  the  ravages  of  phthisis  and  epidemic  diseases. 

Bisulphide  of  carbon  is  used  in  the'  arts  principally  in  the  pro- 
cess of  vulcanizing  India  rubber,  and  for  extracting  oils  from  seeds 
and  fatty  bodies.  The  constant  inhalation  of  the  vapor  of  bisulphide 
of  carbon  produces  a  train  of  symptoms  to  which  attention  was  first 
attracted  by  Delpech  in  1856.  The  symptoms  have  been  observed  fre- 
quently since  that  time.     The  following  account  is  from  Hirt^ : — 

"Some  days,  or  even  weeks  or  months,  after  beginning  this  occu- 
pation, the  workmen  complain  of  a  dull  headache,  becoming  more 
severe  toward  evening.  This  symptom  is  soon  followed  by  joint- 
pains,  formication,  and  itching  on  various  parts  of  the  body.  A  more 
or  less  troublesome  cough  is  present,  but  it  is  not  accompanied  by  any 
characteristic  sputa.  The  respiration  is  regular,  the  pulse  somewhat 
increased  in  frequency.  During  this  time  certain  individuals  exhibit 
a  marked  exaltation  of  their  intellectual  powers ;  they  talk  more  than 
formerly,  and  show  an  interest  in  matters  in  which  they  at  other  times 
show  no  concern.  There  is,  however,  very  rarely  distinct  mental  dis- 
ease. The  sexual  desires  are  increased  in  both  sexes,  menstruation 
becomes  irregular,  and  the  urine  possesses  a  faint  odor  of  bisulphide  of 
carbon.  In  this  manner  several  weeks  or  months  pass  away.  Very 
gradually  the  physical  exaltation  disappears,  and  a  profound  depres- 


'  Chapter  T,  p.  28. 
«  Op.  cit.,  p.  06. 


254  TEXT-BOOK  OF  HYGIENE. 

sion,  melancholy,  and  discouragement  succeed,  coupled  with  which 
is  often  loss  of  memory.  Vision  and  hearing  become  less  acute,  and 
the  sexual  activity  is  completely  destroyed.  Anesthetic  spots  appear 
on  various  parts  of  the  body,  and  numbness  of  the  fingers  prevents 
the  workman  from  performing  any  fine  work." 

The  disease  never  proves  fatal,  but  the  normal  condition  of  the 
individual  is  rarely  re-established  when  the  disorder  has  advanced  to 
the  extreme  stages  mentioned. 

Iodine  and  bromine  vapors,  when  inhaled  by  workmen  engaged 
in  their  preparation,  produce  symptoms  of  poisoning  which  are  some- 
times very  serious.  Acute,  iodic  intoxication  consists  in  severe  laryn- 
geal irritation,  headache,  conjunctivitis,  and  nasal  catarrh.  Oc- 
casionally there  is  temporary  loss  of  consciousness.  Chronic  iodic 
cachexia  is  often  found  among  the  workmen.  In  certain  cases 
atrophy  of  the  testicles  and  gradual  disappearance  of  sexual  power 
have  been  observed.  In  the  manufacture  of  bromine,  a  form  of  bron- 
chial asthma  has  been  observed  among  those  engaged  in  the  establish- 
ment. No  symptoms  corresponding  to  those  of  chronic  iodism  have 
been  observed  among  the  workmen  in  bromine. 

The  inhalation  of  the  vapors  of  turpentine  produces,  in  a  con- 
siderable number  of  those  constantly  exposed  to  them,  diseases  of  the 
respiratory  organs,  beginning  with  cough  and,  at  times,  resulting  in 
consumption.  In  other  cases  derangement  of  the  digestive  organs, 
strangury,  and,  in  a  few  cases,  bloody  urine  have  been  observed. 
Nervous  disturbances  are  rare  after  the  inhalation  of  turpentine,  and 
are  limited  to  headache,  roaring  in  the  ears,  or  flashes  of  light  before 
the  eyes. 

Petroleum  vapor,  when  inhaled  in  a  concentrated  state,  produces 
symptoms  similar  to  those  of  anesthetics.  When  exposed  for  a  long 
time  to  diluted  petroleum  vapor,  workmen  sometimes  suffer  from 
chronic  pulmonary  catarrhs  or  from  nervous  derangements.  Among 
the  latter  are  disturbances  of  mental  activity,  loss  of  memory,  giddi- 
ness, and  headache.  These  symptoms  are,  however,  rare.  More  fre- 
quent are  pustular  or  furuncular  affections  of  the  skin,  which  are 
probably  due  to  the  direct  irritant  effect  of  the  vapor. 

Lead  poisoning  is  one  of  the  most  characteristic  diseases  of  arti- 
sans. It  attacks  workmen  engaged  in  the  roasting  and  smelting  of 
lead  ores ;  in  the  manufacture  of  white  and  red  lead  and  of  lead  ace- 
tate and  chromate ;  in  type-making,  in  painting,  and,  in  short,  in  all 
occupations  in  which  the  workman  is  compelled  to  inhale  the  vapor 
or  dust  of  lead,  or  in  which  it  is  conveyed  in  some  manner  to  the 


DISEASES  DUE  TO  INHALATION  OF  GASES  OR  VAPORS.       255 

digestive  organs.  It  is  believed  also  that  it  can  be  absorbed  by  the 
skin  and  produce  its  poisonous  eii'ects  upon  the  economy.  The  aver- 
age duration  of  life  in  the  roasting  and  smelting  furnaces  is  41  years ; 
of  painters,  as  shown  by  Table  XXXII,  54.07  years.  Of  the  latter  75 
per  cent,  are  attacked  by  one  of  the  forms  of  lead  poisoning,  colic 
being  most  frequent.  In  the  manufacture  of  white  lead  more  than 
half  of  the  workmen  suffer  from  lead  poisoning  during  the  first  year, 
lead  colic  being  present  in  60  per  cent,  of  all  the  cases. 

In  most  sugar-of-lead  manufactories  60  per  cent,  of  all  the  oper- 
atives constantly  suffer  from  some  form  of  lead  poisoning. 

Poisoning  has  also  been  observed  in  workmen  engaged  in  the 
manufacture  of  various  pigments  of  which  the  acetate  of  lead  is  the 
base  {e.g.,  lead  chromates).  Among  type-founders  the  symptoms  of 
lead  poisoning  are  not  very  rare,  and  even  compositors  sometimes 
suffer  from  lead  poisoning.  In  the  latter  case  the  lead  must  be  ab- 
sorbed through  the  skin  in  order  to  produce  its  effects. 

The  various  forms  in  which  lead  poisoning  affects  the  individual 
are  the  lead  cachexia,  manifested  by  loss  of  weight,  discoloration  of 
the  skin,  the  characteristic  blue  lining  along  the  gums,  diminution 
of  the  salivary  secretion,  a  sweetish  taste,  and  offensive  odor  of  the 
breath;  then  lead  colic,  the  features  of  which  are  well  known;  lead 
paralysis,  the  characteristic  "wrist-drop,"  which  requires  prompt  and 
intelligent  treatment,  otherwise  permanent  atrophy  of  the  affected 
muscles  often  takes  place.  Among  other  nervous  manifestations  of 
the  poison  is  a  painful  affection  of  the  lower  extremities,  attacking 
joints  and  flexor  muscles,  and  remittent  in  character.  At  times  anes- 
thesia of  the  skin  of  the  head  and  neck  is  present.  In  rare  cases 
serious  mental  derangement  occurs.  Other  grave  nervous  lesions,  such 
as  the  so-called  saturnine  hemiplegia  and  tabes,  are  happily  extremely 
rare  among  workmen  in  the  metal  at  the  present  day. 

Mercurial  poisoning  is  frequent  among  the  artisans  who  work 
in  the  metal.  The  smelters  of  the  ore  suffer  severely  and  in  a  large 
proportion  of  the  entire  number  employed.  Their  average  age  at 
death  is  45  years.  Mirror-makers  suffer  most  severely  of  all  artisans 
who  come  in  contact  with  the  vapors  of  the  metal.  It  is  beyond  ques- 
tion that  the  confinement  in  badly-ventilated  work-rooms  is  largely 
responsible  for  the  poisonous  effects  of  the  metal  upon  this  class. 
The  special  forms  in  which  the  poisonous  effects  are  manifested  in 
mirror-makers  are  salivation,  mercurial  tremor,  and  nervous  erethism, 
but,  in  addition,  a  very  large  proportion  suffer  from  pulmonary  con- 
sumption.    It  is  stated  that  71  per  cent,  of  the  total  deaths  among 


256  TEXT-BOOK  OF  HYGIENE. 

mirror-makers  (those  who  coat  the  glass  with  the  mercury  alloy)  are 
from  phthisis. 

Among  women  the  symptoms  are  aggravated,  and  abortion  fre- 
quently occurs.  Of  the  children  of  women  suffering  from  mercurial 
poisoning  born  living  at  term,  65  per  cent,  die  within  the  first  year. 

In  the  Almaden  quicksilver  mines  in  Spain  a  considerable  pro- 
portion of  tlie  workmen  suffer  from  the  milder  symptoms  of  mercurial 
intoxication  (gingivitis,  salivation,  or  dryness  of  the  mouth).  The 
more  severe  manifestations  (tremor,  convulsions,  contractures,  violent 
muscular  pains,  paralysis,  cachexia)  are  much  less  frequent,  and  lat- 
terly not  so  severe  as  they  were  formerly. 

Fire-gilders,  fulminate-makers,  and  physical  instrument  makers 
not  infrequently  suffer  from  the  deleterious  effects  of  inhaling  the 
vapor  of  mercury.  Hatters  are  also  liable,  to  a  considerable  extent, 
to  the  poisonous  effects  of  the  metal.® 

It  has  been  found  that  upon  sprinkling  the  floor  of  the  work- 
room of  mirror-makers  with  aqua  ammonia,  so  as  to  impregnate  the 
atmosphere  with  ammonia,  the  bad  effects  of  mercury  on  the  system 
are  markedly  diminished.  Care  must  be  taken,  however,  not  to  use 
the  ammonia  to  excess,  otherwise  the  diseases  caused  by  this  agent  may 
attack  the  workmen. 

Zinc  or  copper  vapors,  or  possibly  a  combination  of  the  two,  given 
off  from  the  brass,  which  is  an  alloy  of  these  metals,  produces  a  pecu- 
liar train  of  symptoms  known  as  ^'brass-founders'  ague."  The  symp- 
toms are  described  by  Hirt,  who  has  suffered  from  two  attacks  of 
the  affection  himself,  as  follows^"  "A  few  hours  after  attending  the 
process  of  brass-casting,  one  notices  a  peculiar,  uncomfortable  sensa- 
tion over  the  whole  body.  More  or  less  severe  pains  in  the  back  and 
general  lassitude  cause  a  discontinuance  of  the  ordinary  occupation. 
While  the  pains  appear  now  here,  now  there,  and  are  extremely  annoy- 
ing, no  changes  in  the  pulse  or  respiration  are  noticeable.  In  a  short 
time,  however,  usually  after  the  patient  has  taken  to  the  bed,  chilli- 
ness comes  on,  which  soon  increases  to  a  decided  rigor,  lasting  fifteen 
minutes  or  longer.  In  the  course  of  an  hour  or  less  the  pulse  now 
reaches  a  rapidity  of  100  to  120  beats  per  minute.  A  tormenting 
cough,  combined  with  a  feeling  of  soreness  in  the  chest,  comes  on. 
In  consequence  of  the  repeated  acts  of  coughing,  the  increasing  frontal 
headache  produces  exceeding  discomfort.    Soon,  however,  usually  after 


'Hatting  as  Affecting  the  Health  of  Operatives,  L.  Dennis,  Report  New 
Jersey  State  Board  of  Health,  1879;    Connecticut  State  Board  of  Health,  1883. 
"Op.  cit.,  p.   122. 


DISEASES  DUE  TO  INHALATION  OF  GASES  OR  VAPORS.       257 

a  few  hours,  the  height  of  the  attack  is  reached;  free  perspiration 
indicates  the  stage  of  defervescence,  and  during  the  gradual  diminu- 
tion of  tlie  symptoms  the  patient  falls  into  a  deep  sleep,  lasting  several 
hours.  On  awakening,  a  slight  headache  and  lassitude  only  remain  as 
reminders  of  the  attack." 

It  is  said  that  about  75  per  cent,  of  the  workmen  in  brass-foun- 
dries are  attacked  by  this  affection ;  the  attack  is  liable  to  be  repeated 
at  every  exposure. 

A  chronic  form  of  poisoning  is  said  to  occur  among  zinc-smelters 
after  following  their  occupation  for  ten  to  twelve  years.  It  consists  of 
hyperesthesia,  formication,  and  burning  of  the  skin  of  the  lower 
extremities,  soon  followed  by  alteration  in  the  temperature  and  tactile 
sensation,  and  diminution  of  the  muscular  sense.  Paresis  of  the  lower 
extremities  sometimes  comes  on.  The  disease  has  not  yet  been  suffi- 
ciently investigated. 

Aniline  vapor  is  exceedingly  poisonous  when  inhaled  in  a  con- 
centrated state.  Hirt  describes  an  acute  form  which  usually  results 
fatally:  "The  workman  falls  suddenly  to  the  ground;  the  skin  is 
cold,  pale ;  the  face  is  cyanotic,  the  breath  has  the  odor  of  aniline,  the 
respiration  is  slowed,  and  the  pulse  increased.  The  sensation,  dimin- 
ished from  the  beginning  of  the  attack,  gradually  entirely  disappears, 
and  death  follows  in  a  state  of  deep  coma."^^  There  is  a  milder 
form  which  comes  on  after  several  days  of  exposure.  It  is  character- 
ized by  laryngeal  irritation,  diminution  of  appetite,  headache,  giddi- 
ness, great  weakness,  and  depression.  The  pulse  is  rapid,  small,  and 
irregular.  Eespiration  is  little  altered.  There  is  decrease  of  sensibility 
of  the  skin.  Convulsions  may  occur,  but  are  usually  of  short  dura- 
tion. 

The  chronic  form  of  aniline  poisoning  i^  characterized  by  three 
sets  of  symptoms :  those  affecting  -the  central  nervous  system,  the 
digestive  tract,  and  the  skin.  Among  the  first  are  lassitude,  headache, 
roaring  in  the  ears,  and  disturbances  of  sensation  and  motion  of 
greater  or  less  degree. 

The  digestive  derangements  consist  in  eructation^,  nausea,  and 
vomiting. 

The  cutaneous  lesions  are  eczematous  or  pustular  eruptions,  and 
sometimes  round,  sharply-circumscribed  ulcers  with  callous  borders. 

There  is  no  trustworthy  evidence  that  in  the  manufacture  of 
aniline  colors  poisonous  symptoms  are  produced  in  the  workmen. 


''Op.  cit.,  p.  127. 


258  TEXT-BOOK  OF  HYGIENE. 

2— DISEASES  DUE  TO  THE  INHALATION  OF  IRRITATING 
OR  POISONOUS  DUST. 

The  inhalation  of  air  containing  particles  of  organic  or  inor- 
ganic matter  has  long  been  accepted  as  a  cause  of  certain  special  dis- 
eases of  artisans.  The  diseases  so  caused  are  usually  limited  to  the 
pulmonary  organs,  and  consist  of  acute  and  chronic  catarrh,  emphy- 
sema of  the  lungs,  pneumonia,  interstitial  inflammation  of  the  lungs — 
the  so-called  fibroid  phthisis  or  pulmonary  cirrhosis. 

Coal-dust  is  inhaled  by  coal-miners,  charcoal-burners,  coal-handlers, 
firemen,  chimney-sweeps,  foundry-men,  lead-pencil  makers,  etc. 
Chronic  bronchial  catarrhs  are  most  frequent,  while  phthisis  and 
emphysema  are  almost  absent  from  the  list  of  diseases  affecting  these 
workmen.  Dr.  W.  B.  Canfield  has  reported  an  interesting  case  of 
pneumonoconiosis  in  which  there  was  coincident  bacillary  phthisis.^^ 
The  table  on  page  247  shows  that  the  expectation  of  life  of  foundry- 
men,  furnace-men,  firemen,  and  chimney-sweeps  is  much  below  the 
average. 

Metallic  dust  is  inhaled  by  blacksmiths,  nailers,  cutlers,  lock- 
smiths, file-cutters,  cutlery-  and  needle-  polishers,  etc.  While  in  this 
class  of  workmen  cases  of  bronchitis  and  pneumonia  are  relatively 
frequent,  much  the  largest  proportion  suffer  from  phthisis.  A  tab^e 
compiled  by  Hirt  shows  that  out  of  the  total  number  of  sick  in  the 
different  classes  of  workmen  the  cases  of  phthisis  were : — 

62.2  per  cent,  for  file-cutters, 

69.6         "  "     needle-polishers, 

40.4         "  "     grinders, 

12.2         "  "     nailers. 

The  Massachusetts  table  gives  the  average  duration  of  life  for 
blacksmiths  at  53.26  years,  of  nail-makers  at  41.49  years,  and  of  cut- 
lers at  39,21  years.  The  needle-polishers  at  Sheffield,  as  already 
stated,  have  only  an  average  duration  of  life  of  30.66  years.  In  this 
work  and  that  of  grinding  knives,  scissors,  and  similar  articles,  the 
metallic  dust  is  mixed  with  mineral  dust  (particles  of  silica  from 
the  grindstone).  This  mixture  seems  to  be  much  more  deleterious 
than  metallic  dust  alone,  as  shown  by  the  shorter  average  duration 
of  life  and  the  enormous  percentage  of  cases  of  consumption. 

Mineral  dust  is  inhaled  by  the  workmen  in  a  large  number  of  diff- 
erent industries.  The  grinders  in  the  ground-glass  factories  suffer 
most  severely.     Hirt  found  the  average  duration  of  life  in  grinders 


»2  Trans.  Med.  and  Chir.  Fac,  Md.,   1889. 


DISEASES  DUE  TO  INHALATION  OF  DUST.  259 

who  began  this  occupation  after  their  25th  year  to  be  42.50  years, 
while  in  those  who  began  at  the  age  of  15  the  average  duration  was 
30  years. 

Millstone  cutting  is  also  a  very  dangerous  occupation.  Peacock^^ 
gives  the  average  age  of  these  workmen  at  24.1  years.  Stone-cutters 
generally  suffer  frequently  from  phthisis,  probably  largely  in  conse- 
quence of  the  constant  inhalation  of  the  mineral  dust  produced  dur- 
ing their  work.  The  Massachusetts  table  gives  the  average  age  at 
death  of  these  workmen  at  40.90  years,  while  Hirt's  table  gives  a  much 
lower  age,  namely,  36.3  years.  Potters  and  porcela'n-makers  are  ex- 
posed to  similar  dangers  from  their  occupation,  but  to  a  much  less 
degree.  The  table  on  page  247  gives  the  average  age  at  death  at  56.67 
years — rather  a  high  average. 

Slaters  and  workmen  in  slate-quarries  suffer  in  a  large  propor- 
tion of  cases  from  chronic  pneumonia,  and  die  at  a  comparatively 
early  age. 

Masons  and  carpenters  have  an  average  duration  of  life  of  50.33 
and  53.33  years,  respectively.  One-third  of  all  the  diseases  from  which 
they  suffer  affect  the  respiratory  organs. 

Gussenbauer  has  reported  a  very  interesting  series  of  cases  of  a 
peculiar  inflammatory  affection  of  the  diaphyses  of  the  long  bones  in 
the  artisans  who  are  engaged  in  the  manufacture  of  pearl  buttons. 

Gem-finishers  are  exposed  not  only  to  the  inhalation  of  dust,  but 
to  poisonous  gases  (carbon  monoxide)  and  vapors  (lead).  The  pro- 
portion of  sickness  among  them  is  very  high. 

Vegetable  Dust. — The  workmen  compelled  to  inhale  vegetable 
dust  are  those  who  work  in  tobacco,  cotton-operatives,  flax-dressers, 
paper-makers,  weavers,  wood-turners,  millers,  and  laborers  in  grain- 
elevators. 

Workmen  in  tobacco  usually  suffer,  within  a  few  weeks  after 
beginning  work,  from  a  nasal,  conjunctival,  and  bronchial  catarrh, 
which  soon  passes  off,  as  the  mucous  membranes  seem  to  become  ac- 
customed to  the  irritation.  Nausea  is  also  frequent  at  flrst,  due 
probably  to  the  absorption  of  small  quantities  of  nicotine.  Females 
exposed  to  the  tobacco-dust  usually  suffer  from  digestive  and  nervous 
troubles.    They  are  also  said  to  abort  frequently. 

Dr.  E.  S.  Traey,^*  as  a  result  of  his  observations  among  cigar- 
makers  in  New  York,  states  that  the  fecundity  of  these  people  is  much 


"  Quoted  by  Merkel,  in  von  Pettenkofer  und  Ziemssen's  Handbueh  der 
Hygiene,  IT  Th.,  4  Abth.,  p.  197. 

"  Buck's  Hygiene  and  Public  Health,  vol.  ii,  p.  62. 


260  TEXT-BOOK  OF  HYGIENE. 

less  than  the  average.  Three  hundred  and  twenty-five  families 
visited  had  only  465  children,  an  average  of  1.43  to  each  family.  Dr. 
Tracy  is  inclined  to  attribute  this  to  the  frequent  abortions  that  occur 
among  the  females  exposed  to  the  inhalation  of  tobacco-dust.  Accord- 
ing to  the  Massachusetts  table,  cigar-making  is  an  •unfavora;ble  occu- 
pation, the  average  age  at  death  being  38.36  years. 

Cotton-operatives,  flax-dressers,  weavers,  and  workmen  in  paper- 
mills  are  subject  to  various  diseases  of  the  respiratory  organs.  Coetsem, 
as  long  ago  as  1836,  described  a  peculiar  pulmonary  affection  among 
cotton-operatives,  which  he  termed  pneumonie  cotonneiise.  The  observa- 
tion does  not  seem  to  have  been  verified  by  others;  at  all  events,  the 
author  is  unable  to  find  any  other  record  of  a  similar  affection  in  the 
literature  of  the  subject.  Among  weavers  the  mortality  from  phthisis 
is  comparatively  high.  Among  paper-makers  Hirt  found  an  average 
duration  of  life  of  37.6  years.  The  people  who  sort  rags  are  liable  to 
a  fatal  infectious  disease,  "rag-sorters'  disease"  (Hadernkrankheit^^), 
which  resembles  in  all  respects,  and  is  probably  nothing  less  than, 
anthrax.  No  cases  have  been  reported  in  this  country,  but,  as  the 
importation  of  rags  from  abroad  is  carried  on  to  a  considerable  extent, 
no  apology  is  believed  to  be  necessary  for  calling  attention  to  it.  The 
"wool-sorters'  disease"  is  similar  in  its  nature. 

Millers  suffer  in  a  large  proportion  of  cases  from  pulmonary  af- 
fections, especially  bronchial  catarrh  and  pneumonia.  According  to 
Hirt,  20.3  per  cent,  of  all  the  diseases  of  these  workmen  are  pneu- 
monias, 9.3  per  cent,  bronchial  catarrhs,  10.9  per  cent,  phthisis,  and 
1.9  per  cent,  emphysema.  The  average  duration  of  life  is  45.1  years. 
The  Massachusetts  table  gives  57.14  years — a  very  much  more  favor- 
able exhibit.. 

The  laborers  in  grain-elevators  are  compelled  to  inhale  a  very 
irritating  dust,  which  causes  acute  and  chronic  catarrhs  of  the  re- 
spiratory organs.  Dr.  T.  B.  Evans,  of  Baltimore,  has  reported  a  series 
of  cases  of  catarrhal  pneumonia  in  these  workmen,  which  were  char- 
acterized by  some  very  peculiar  features.  Brush-making,  according 
to  the  statistics  of  Hirt,  is  a  very  dangerous  occupation.  Nearly  one- 
half  of  the  deaths  among  brush-makers  are  from  phthisis,  due,  in  great 
measure,  to  the  inhalation  of  the  sharp  fragments  of  bristles  produced 
in  trimming  the  brushes.  In  the  Massachusetts  table  the  average 
duration  of  life  is  given  at  43.11  3^ears. 


See  article  by  Soyka,  Realencyclopaedie  d.  ges.  Heilk,  Bd.  VI,  p.   165. 


DISEASES   DUE   TO   POISONOUS   SUBSTANCES.  261 

3 DISEASES  DUE  TO  THE  ABSORPTION  OR  LOCAL  ACTION 

OF   IRRITATING   OR   POISONOUS   SUBSTANCES. 

Arsenic  is  used  in  the  manufacture  of  green  pigments  and  for 
various  other  purposes  in  the  arts.  In  the  preservation  of  furs  and 
in  taxidermy  it  finds  extensive  use.  In  the  preparation  of  the  pigment 
known  as  Paris  green  the  workmen  are  frequently  entirely  covered 
by  a  layer  of  the  poisonous  salt.  The  poisonous  symptoms  occur  in 
consequence  of  the  absorption  of  the  poison  through  the  skin  or  from 
its  local  action,  and  but  rarely  on  account  of  inhalation  of  vapors  or 
dust  in  which  it  is  contained.  The  most  marked  symptoms  are 
chronic  gastric  catarrh,  superficial  erosions  in  the  mouth,  dry  tongue, 
thirst,  and  a  burning  sensation  in  the  throat.  These  symptoms  may 
continue  for  months,  or  even  years,  and  gradually  produce  a  com- 
plete breaking  down  of  nutrition  and  the  vital  powers.  Violent  itch- 
ing skin  eruptions  of  an  eczematous  character  are  not  infrequent  com- 
plications of  the  internal  symptoms. 

Lewin  has  described  a  localized  pigmentation  of  the  skin  in 
workmen  (engravers)  in  silver.  The  left  hand  is  especially  affected. 
The  occurrence  of  the  affection  is  explained  by  the  numerous  slight 
injuries  of  the  hands  by  the  graver's  tools  and  the  local  absorption 
and  decomposition  of  the  silver. 

Phosphorus  produces  two  classes  of  effects  in  persons  subjected  to 
its  influence.  The  milder  effects  are  produced  by  the  inhalation  of 
the  fumes  of  the  substance,  and  are  limited  to  digestive  disturbances 
and  diseases  of  the  pulmonary  organs.  The  severer  s}Tnptoms  are 
only  observed  among  the  employes  in  match-factories,  and  are  due 
to  the  local  action  of  the  phosphorus  upon  the  tissues  affected. 

The  characteristic  disease  produced  by  phosphorus  is  a  painful 
periostitis  of  the  lower  or  upper  jaw.  The  limitation  of  the  affection 
to  this  locality  is  believed  to  be  due  to  the  action  of  the  phosphorus 
dissolved  in  the  saliva.  The  fact  that  the  lower  jaw,  with  which  the 
saliva  comes  more  thoroughly  in  contact,  is  most  frequently  affected 
seems  to  indicate  that  this  view  is  the  correct  one.  The  disease  be- 
gins, on  an  average,  five  years  after  the  beginning  of  the  employment. 
Hirt  estimates  the  proportion  of  employes  in  match-factories  attacked 
at  11  to  12  per  cent.  The  first  symptom  of  the  disease  is  toothache, 
soon  extending  to  the  jaw.  The  cervical  glands  swell  up;  the  gums 
become  reddened  and  spongy;  abscesses  form  about  the  diseased  teeth, 
from  which  large  quantities  of  thin,  offensive  pus  are  discharged. 
Examination    with    a   sound    reveals    carious,   nodulated   bone.      The 


262  TEXT-BOOK  OF  HYGIENE. 

cheeks  become  swollen,  erysipelatous,  and  may  suppurate  and  discharge 
pus  externally. 

Hutchinson  has  reported  a  case  in  which  the  long-continued  in- 
ternal administration  of  phosphorus  as  a  medicine  produced  maxillary 
necrosis. 

The  destruction  of  the  soft  tissues  continues  until  resection  of 
the  jaw  is  finally  undertaken  and  the  disease  checked  by  surgical  in- 
tervention, and  removal  of  the  patient  from  the  influence  of  the  per- 
nicious substance. 

Dr.  J.  Ewing  Mears  reported^*'  16  cases  of  phosphorus  necrosis. 
He  concluded  "that  the  antidotal  powers  of  turpentine  have  been  es- 
tablished, both  in  neutralizing  the  effects  of  the  poison  upon  operatives 
during  their  work  and  also  in  the  treatment  of  the  early  stage  of 
the  disease.  The  disease  is  to  be  prevented  by  the  adoption  of  thor- 
ough methods  of  ventilation,  stringent  rules  with  regard  to  c]eanli- 
ness,  and  the  free  disengagement  of  the  vapors  of  turpentine  in  all 
the  apartments  of  factories  in  which  the  fumes  of  phosphorus 
escape." 

In  the  manufacture  of  quinine  a  troublesome  eczema  is  caused  in 
about  90  per  cent  of  the  employes.  It  seems  to  be  due  to  emanations 
given  off  from  the  boiling  solutions.  It  begins  with  intense  itching, 
followed  by  swelling  and  the  formation  of  vesicles,  which  soon  burst 
and  form  crusts.  There  is  considerable  fever  when  the  swelling  is 
great.  It  is  said  that  blondes  are  more  frequently  affected  than  those 
of  dark  complexion.  The  disease  soon  disappears  if  the  work  is 
given  up. 

The  workmen  engaged,  in  the  manufacture  of  bichromate  of 
potassium  are  said  to  suffer  from  an  ulceration  of  the  nasal  mucous 
membrane  very  similar  to  that  already  described  as  due  to  the  vapors 
of  hydrochloric  acid  (p.  250).  Eapidly-spreading,  deep  ulcers  are 
also  said  to  form  if  the  bichromate  comes  in  contact  with  abraded  sur- 
faces of  the  skin. 

The  strong  alkali  handled  by  tanners  frequently  produces  fissured 
eczemas  of  the  hands,  which  are  painful  and  often  difficult  to  cure. 

The  workmen  in  petroleum  refineries  frequently  suffer  from  acnei- 
form  or  furuncular  eruptions. 

Among  glass-blowers,  syphilis  is  frequently  communicated  by  an 
infected  mouth-piece  which  is  used  by  the  men  in  turn. 


^^  Trans.   Am.   Surg.   Association,   1887. 


DISEASES  DUE  TO  EXCESSIVE  USE  OF  ORGANS.  263 

4 DISEASES    DUE    TO    EXPOSURE    TO    ELEVATED    OR 

VARIABLE    TEMPERATURE     OR    ATMOSPHERIC 
PRESSURE. 

Cooks  and  bakers  are  exposed  almost  constantly  to  a  high  tem- 
perature, which  produces  an  unfavorable  influence  upon  health  and 
predisposes  them  to  diseases  of  various  kinds.  The  Massachusetts 
table  shows  that  cooks  have  a  much  shorter  duration  of  life  than 
bakers,  although  the  statistics  of  both  trades  are  unfavorable. 

The  prevailing  diseases  among  cooks  and  bakers  are  rheumatism 
and  eczematous  eruptions,  generally  confined  to  the  hands,  forearms, 
and  face. 

Blacksmiths,  founders,  and  firemen  suffer  from  the  intense  heat 
to  which  they  are  exposed,  in  addition  to  the  inhalation  of  coal-dust, 
as  has  already  been  pointed  out.  The  stokers  in  the  engine-rooms  of 
steamships  suffer  especially  from  the  excessively  high  temperature  to 
which  they  are  subjected  by  their  occupation.  A  form  of  heart- 
weakness,  described  by  Levick  as  "fireman's  heart,"  is  prevalent  among 
them. 

Sailors,  farmers,  coachmen,  car-drivers,  and  teamsters  are  sub- 
jected to  stress  of  weather,  changes  of  temperature,  and  storms.  They 
suffer  frequently  from  rheumatism,  acute  bronchitis,  pneumonia,  and 
Bright's  disease.  Car-drivers  are  said  also  to  suffer  from  painful 
swelling  of  the  feet,  varicose  veins  and  ulcers,  and  mild  spinal 
troubles.^'^ 

Sun-stroke  is  not  confined  to  any  class  of  artisans,  but  persons 
who  perform  very  hard  labor,  especially  in  a  confined  atmosphere, 
suffer  most  frequently. 

The  effects  of  compressed  air  on  workmen  in  tunnels  and  deep 
mines  have  already  been  referred  to.^^  The  most  serious  symptoms 
occur  not  when  the  individual  is  subjected  to  the  increased  pressure, 
but  when  the  pressure  is  too  rapidly  diminished. 

5 — DISEASES   DUE  TO   THE   EXCESSIVE  USE   OF  CERTAIN 

ORGANS. 

The  prevalent  belief  that  the  overuse  of  the  intellectual  facul- 
ties is  a  frequent  cause  of  mental  disease  is  not  borne  out  by  facts. 
Men  and  women  who  perform  an  amount  of  mental  work  regarded  by 


"A.  McL.  Hamilton  in  Report  New  York  Board  of  Health,  p.  444.  1873. 
wCJiantcr  T,  p.  ]  1 . 


264  TEXT-BOOK  OF  HYGIENE. 

most  persons  as  excessive  have,  in  spite  of  this,  a  long  duration  of  life. 
There  are  no  exact  statistics  upon  this  subject, "  but  Caspar  made 
the  following  estimate  of  the  average  duration  of  life  among  pro- 
fessional men:  Clergymen  live  65;  merchants,  62 A;  officials,  61.7; 
lawyers,  58.9 ;  teachers,  56.9 ;  and  physicians,  56.8  years.  In  the 
table  on  page  248  the  figures  are  somewhat  less  favorable,  although 
corresponding  in  general  with  those  of  Caspar.  Hence,  it  is  seen 
that,  of  professional  men,  those  whose  occupation  compels  the  exer- 
cise of  high  mental  powers  have  a  higher  duration  of  life  than  any 
other  class,  except  farmers  and  mechanics  engaged  actively  out  of 
doors.  Those  professional  occupations  only  which  necessitate  a  more 
or  less  irregular  mode  of  life  and  frequent  subjection  to  physical  ex- 
haustion and  dangers  from  contagious  disease,  such  as  the  work  of 
physicians  and  journalists,  make  an  unfavorable  showing  in  the  statis- 
tics. The  proposition  may  be  laid  down  that  it  is  not  mental  activity, 
however  great,  but  mental  worry  that  tends  to  the  abbreviation  of  life. 

The  occupation  of  a  tea-taster  is  said  to  produce  a  peculiar  ner- 
vous condition,  manifested  in  muscular  tremblings,  etc.,  which  com- 
pels the  individual  to  give  up  the  work  in  a  few  years. 

Persons  who  test  the  quality  of  tobacco,  an  occupation  corres- 
ponding to  that  of  tea-taster,  are  said  to  suffer  from  nervous  symptoms 
which  may  include  amaurosis  and  other  grave  affections. 

Those  persons  who  are  compelled  to  use  their  eyes  constantly 
upon  minute  objects  frequently  suffer  from  defective  vision.  So  en- 
gravers,- watch-makers,  and  seamstresses  are  liable  to  near-sighted- 
ness, amaurosis,  and  irritation  of  the  conjunctiva.  Public  speakers 
and  singers  frequently  suffer  from  catarrhal  or  even  paretic  condi- 
tions of  the  throat,  which  usually  disappear  on  relinquishing  the 
occupation  for  a  time. 

Telegraph  operators  and  copyists  suffer  from  a  peculiar  convulsive 
affection  of  the  fingers,  called  "writers'  cramp."  Cigar-makers  are  also 
said  to  suffer  from  a  similar  cramp  of  the  fingers  used  in  rolling  cigars. 
Performers  on  wind  instruments  are  liable  to  pulmonary  emphysema, 
on  account  of  the  pressure  to  which  the  lungs  are  frequently  subjected. 
Boiler-makers  often  suffer  from  deafness,  in  consequence  of  their  con- 
stant existence  in  an  atmosphere  in  a  state  of  continual  violent  vibra- 
tion. The  affection  is  generally  recognized  as  'toiler-makers'  deaf- 
ness.^' Dr.  C.  S.  Tumbull  has  reported  several  cases  of  "mill-opera- 
tives' deafness."  Its  characteristic  is  an  inability  to  hear  distinctly 
except  during  a  noise. 


DISEASES  DUE  TO  MECHANICAL  VIOLENCE.  265 

6 DISEASES   DUE  TO   A   CONSTRAINED   ATTITUDE   AND 

SEDENTARY  LIFE. 

It  is  probable  that  the  large  mortality  and  morbidity  rate  of  per- 
sons whose  occupations  keep  them  confined  within  doors  are  due,  next 
to  the  defective  ventilation,  to  the  constrained  attitude  which  most 
of  them  necessarily  assume.  Thus,  carvers,  book-binders,  engravers, 
jewelers,  printers,  shoe-makers,  book-keepers,  and  cigar-makers  all 
have  a  low  average  duration  of  life.  It  is  found,  likewise,  that  many 
of  these  artisans  suffer  most  from  pulmonary  and  digestive  troubles, 
among  the  former  being  phthisis,  and  among  the  latter  constipation, 
dyspepsia,  and  hemorrhoids. 

7 DISEASES  FROM  EXPOSURE  TO  MECHANICAL 

VIOLENCE. 

It  will  be  seen,  by  reference  to  the  table  on  page  248,  that  all 
persons  whose  occupations  involve  an  intimate  contact  with  machinery, 
and  in  the  pursuit  of  which  accidents  frequently  happen,  have  a  short 
duration  of  life.  Persons  liable  to  these  dangers  are  machinists, 
operatives  in  factories,  workmen  in  powder-mills,  baggage-masters, 
brakemen,  drivers,  engineers,  firemen,  and  other  workmen  on  rail- 
roads. Aside  from  the  diseases  to  which  some  of  these  classes  are 
liable  in  consequence  of  exposure  to  variable  atmospheric  conditions, 
the  grave  accidents  to  which  they  are  so  frequently  exposed  render 
their  occupations  extremely  dangerous.  Brakemen  on  freight  rail- 
roads, for  example,  are  classed  by  insurance  companies  as  the  most 
hazardous  "risks,"  and  some  companies  refuse  to  take  them  at  all. 
The  table  on  page  248  tends  to  confirm  the  conclusion  of  the  insurance 
companies,  for,  excluding  the  class  of  "students,"  which,  for  manifest 
reasons,  cannot  be  used  as  a  comparison,  brakemen  have  the  shortest 
average  duration  of  life  of  all  the  occupations  noted  in  the  table. 


QUESTIONS  TO  CHAPTER  IX* 
INDUSTRIAL  HYGIENE. 

How  may  various  occupations  induce  disease?  Are  such  diseases  always 
necessarily  due  to  the  occupations,  or  are  there  incidental  factors  that  might 
be  avoided?  What  classes  of  men  have  the  greatest  expectation  of  life?  What 
occupations  are  especially  unfavorable  to  health?  What  diseases  do  they 
usually  produce?     How  may  diseases  of  occupations  be  conveniently  classified? 

What  disorders  are  liable  to  be  produced  by  the  inhalation  of  the  gases 
of  the  mineral  acids?  What  peculiar  symptoms  may  be  due  to  the  constant 
inhalation  of  the  fumes  of  hj'drochloric  acid?  What  effect  has  ammonia  gas? 
What  disease  is  frequently  due  to  the  constant  inhalation  of  chlorine  gas? 
What  other  disease  is  also  especially  favored  by  it?  What  are  some  of  the 
symptoms  produced  by  the  gas  in  a  concentrated  state?  By  the  constant 
inhalation  of  the  gas? 

In  what  occupations  is  carbon  monoxide  often  given  off  to  the  air? 
What  are  some  of  the  acute  symptoms  produced  by  it?  What  of  the  chronic 
poisoning  by  gas  ?  Is  there  any  evidence  that  carbon  dioxide  in  small  amounts 
may  cause  symptoms  of  chronic  poisoning?  What  are  some  of  the  manifesta- 
tions in  cases  of  acute  poisoning  by  this  gas?  W^hat  other  gas  is  often  found 
in  mines,  and  how  may  it  be  dangerous  to  life?  How  may  its  dangers  be 
avoided  ? 

Where  may  sulphuretted  hydrogen  be  found  in  quantities  sufficient  to 
produce  serious  results?  What  are  some  of  the  evil  effects  due  to  the  inhala- 
tion of  the  vapor  of  bisulphide  of  carbon?  Of  iodine  and  bromine?  Of  tur- 
pentine?    Of  petroleum? 

In  what  occupations  are  the  laborers  subject  to  lead  poisoning?  What 
effect  has  it  on  the  duration  of  life?  In  what  forms  may  lead  poisoning  mani- 
fest itself?     What  proportion  of  workers  in  lead  are  affected  by  it? 

What  proportion  of  workers  in  mercury  are  affected  by  that  metal? 
To  what  disease  are  mirror-makers  especially  prone?  What  are  some  of  the 
symptoms  of  mercurial  intoxication?  What  peculiar  effect  has  the  metal 
upon  female  laborers  and  their  children?  How  may  the  bad  effects  of  mer- 
cury be  diminished? 

What  are  the  symptoms  of  "brass-founders'  ague"?  Is  it  common  among 
the  class   indicated?     What  symptoms  may  indicate  chronic  zinc   poisoning? 

What  are  the  symptoms  of  acute  poisoning  by  aniline  vapor?  What 
peculiarities  characterize  chronic  aniline  poisoning?  Are  these  or  others 
liable  to  be  produced  in  those  employed  in  the  manufacture  of  aniline  colors? 

(266) 


QUESTIONS  TO  CHAPTER  IX.  267 

What  class  of  diseases  is  especially  apt  to  be  caused  by  the  continued 
inhalation  of  dust?  What  is  the  most  common  affection  among  those  who 
inhale  coal-dust  in  large  quantities?  From  what  pulmonary  disease  are  they 
exceptionally  free?  Is  the  expectation  of  life  among  this  class  of  workmen 
high?  What  diseases  seem  to  be  especially  favored  by  the  inhalation  of 
metallic  dust?  Which  of  these  is  the  most  frequent?  What  is  the  effect  of 
a  mixture  of  metallic  and  mineral  dust?  What  occupations  have  a  high  mor- 
bidity and  mortality  from  phthisis?  What  from  chronic  pneumonia  or  other 
pulmonary  affections?  To  what  peculiar  affection  are  pearl-button-makers 
subject  ? 

What  workmen  habitually  inhale  vegetable  dust?  What  disturbances 
are  due  to  the  inhalation  of  tobacco-dust?  What  effect  has  it  on  fecundity, 
and  why? 

To  what  diseases  are  workers  in  cotton  and  flax  subject,  and  from  which 
one  especially  is  the  mortality  high?  What  is  the  average  duration  of  life 
among  paper-makers?  To  what  disease  are  rag-  and  wool-  sorters  liable? 
From  what  affections  do  millers  and  workers  in  grain-elevators  suffer?  Why 
is  the  mortality  from  phthisis  so  high  among  brush-makers? 

What  substances  are  liable  to  cause  disease  by  absorption  or  local  action? 
What  are  some  of  the  symptoms  common  to  those  working  with  arsenic? 
What  two  classes  of  effects  are  observed  among  those  exposed  to  phosphorus 
vapors?  To  what  is  each  class  due?  What  may  be  used  as  a  preventive  and 
antidote  to  such  cases  of  phosphorus  poisoning?  What  malady  is  associated 
with  the  manufacture  of  quinine?  What  other  substances  may  produce  eczema 
or  ulceration  in  their  preparation  or  manufacture? 

What  diseases  are  favored  by  continued  exposure  to  high  temperatures? 
In  what  occupations  are  such  disturbances  accordingly  prevalent?  What 
class  of  laborers  are  subject  to  sudden  changes  or  to  extremes  of  temperature? 
What  are  some  of  the  maladies  that  may  be,  in  part,  traced  to  such  cases  ? 
What  are  the  effects  of  compressed  air  upon  laborers  in  it,  and  when  are 
they  manifested? 

What  diseases  or  disturbances  may  be  due  to  the  excessive  use  of  certain 
organs?  Is  there  any  evidence  that  excessive  mental  activity  leads  to  men- 
tal disease?  What  is  a  factor  in  the  production  of  the  latter?  Why  is  the 
mortality- rate  so  high  among  those  who  follow  sedentary  or  in-door  occupa- 
tions? What  disturbances  are  most  common  to  these  pursuits?  In  what 
occupations  are  the  laborers  especially  liable  to  mechanical  violence?  Is  the 
average  duration  of  life  of  such  workmen  low  qr  high? 


CHAPTER  X. 

MILITARY  AND  CAMP  HYGIENE. 

Hygiene  applying  especially  to  military  life  has  made  great  ad- 
vances in  recent  years,  and  as  the  causes  of  epidemic  diseases  formerly 
considered  the  inevitable  accompaniment  of  war  have  one  by  one  been 
made  manifest,  many  fatal  camp  maladies  have  lost  in  the  eyes  of  the 
medical  officer  much  of  their  former  menace. 

The  soldier  of  the  present  day  has  many  more  comforts  than 
before.  Each  year  sees  the  adoption  of  improvements  in  food,  shelter, 
or  clothing,  while  the  care  of  the  sick  and  wounded  in  active  service 
approaches  more  nearly  an  ideal  standard. 

I THE  RECRUIT. 

The  raw  recruit,  sometimes  awkward  and  slovenly,  often  unpre- 
possessing in  appearance,  is  the  material  from  which  armies  are  made. 

The  selection,  therefore,  of  men  capable  physically  and  mentally 
of  being  trained  into  disciplined  soldiers  lies  at  the  very  foundation  of 
military  hygiene.  At  first  glance  nothing  would  seem  to  be  easier 
than  for  a  physician  to  detect  unsoundness  in  an  applicant  for  a 
soldier's  life.  As  a  matter  of  fact,  experience  and  knowledge  of  mil- 
itary conditions  are  requisites  to  properly  select  recruits.  Many  de- 
fects of  structure  in  no  way  affecting  the  actual  bodily  health,  or, 
from  the  standpoint  of  the  examiner  of  life  insurance,  the  expecta- 
tion of  life,  are  properly  considered  bars  to  enlistment.  A  man  suffer- 
ing from  or  predisposed  to  disease  is  of  course  at  once  rejected,  but 
the  accepted  recruit  must  have  the  free  use  of  all  of  his  limbs;  his 
hearing,  vision,  and  speech  must  be  perfect;  he  must  be  of  ample 
chest  measurement  and  justly  proportioned.  An  inquiry  must  also 
be  made  into  his  personal  ,and  family  history,  and  persons  presenting 
the  appearance  of  tramps,  vagabonds,  or  hard  drinkers,  or  manifesting 
lack  of  intelligence,  are  to  be  rejected,  even  if  apparently  able-bodied. 

Only  under  very  exceptional  circumstances  are  recruits  under 
21  years  old  accepted  in  the  United  States  army.  Some  medical 
officers  of  experience  think  that  for  tropical  service  the  minimum  age 
should  be  even  greater,  and  that  an  ideal  army  for  such  service  would 
be  composed  of  men  between  25  and  45  years  of  age. 
(268) 


THE  TRAINING  OF  THE  SOLDIER.  269 

The  height  of  a  recruit  is  at  present  fixed  at  5  feet  4  inches  as 
a  minimum  for  all  branches. 

The  maximum  height  for  cavalry  is  5  feet  10  inches,  and  the 
maximum  for  artillery  and  infantry  is  governed  by  the  rule  for 
weight,  as  follows : — 

The  minimum  weight  for  all  recruits  is  124  pounds,  except  for 
the  cavalry,  in  which  enlistment  may  be  made  without  regard  to  a 
minimum  weight  if  proportions  and  chest-measurements  are  satis- 
factory. The  maximum  weight  for  artillery  and  infantry  is  190 
pounds,  for  cavalry  and  light  artillery,  165  pounds. 

Up  to  and  including  the  height  of  67  inches  the  recruit  should 
weigh  2  pounds  for  every  inch.  The  same  rule  applies  to  men  of 
greater  height,  but  with  the  addition  of  5  pounds  for  every  inch 
above  67. 

The  difference  between  the  chest-measurement  at  inspiration  and 
expiration  should  be  at  least  2  inches  in  men  of  67  inches  in  stature 
or  below,  and  2i/^  inches  above  that  height. 

These  rules  are  considered  to  give  a  fair  standard  of  physical  pro- 
portions, but  a  slight  deviation  from  them  is  allowed  in  specially  de- 
sirable recruits.    Vaccination  of  all  accepted  men  is  compulsory. 

2 THE  TRAINING   OF  THE   SOLDIER. 

The  preliminary  drill  of  a  recruit  is  generally  purely  calisthenic. 
The  "setting-up  drill"  of  the  United  States  army  is  admirably 
adapted  for  its  purposes,  to  render  the  recruit  supple  and  alert,  quick 
to  respond  to  the  word  of  command,  and  to  give  him  an  upright  and 
graceful  carriage.  Although  especially  intended  for  the  recruit,  a 
certain  amount  of  this  exercise  is  given  to  all  soldiers  throughout  their 
entire  period  of  service. 

All  the  muscles  of  the  body  are  brought  into  play,  and  the  effects 
of  the  exercise  on  the  muscular  development  of  young  and  ungainly 
recruits  are  soon  seen. 

The  movements  in  the  manual  of  drill  with  the  rifle  have  the  dis- 
advantage of  being  largely  unilateral,  and  when  once  learned  are  so 
automatically  performed  that  the  calisthenic  benefit  of  bodily  exercise 
is  not  to  any  extent  gained  thereby. 

Exercises  of  agility  are  practiced  by  cavalrymen  and  light  arlil- 
lerymen  especially.  The  skill  attained  in  fancy  horsemanship  by 
many  of  the  soldiers  is  only  excelled  by  the  best  professional  circus- 


270  TEXT-BOOK  OF  HYGIENE. 

riders.  For  infantry,  wall-scaling  and  the  crossing  of  obstacles  wliile 
carrying  arms  and  equipment  are  taught. 

Exercises  of  endurance  consist  of  practice  marches  with  full 
equipment,  and  lastly  there  is  the  special  training  in  the  use  of  the 
implements  of  war. 

The  defective  recruit  who  has  been  improperly  selected,  very 
soon,  under  military  training,  shows  his  incapacity  for  the  service. 
A  man  with  fiat-foot  plays  out  on  the  march ;  with  a  crippled  thumb 
he  can  never  properly  handle  his  rifle;  with  .even  a  slight  defect  in 
hearing  he  spoils  the  manual  of  his  company  by  inability  to  properly 
catch  the  word  of  the  drill-master.  These  are  samples  of  some  of  the 
commoner  defects  which  are  often  overlooked  in  apparently  able- 
bodied  men  by  the  average  physician  examining  men  for  the  military 
service,  and  which  must  be  specially  guarded  against  when  war  re- 
quires the  enrollment  of  thousands  of  volunteers,  and  when  inex- 
perienced medical  examiners  must  of  necessity  be  relied  upon. 

3 ^THE  FOOD  OF  THE  SOLDIER. 

An  army  ration  is  one  day's  allowance  for  one  soldier.  The 
rations  for  an  organization  are  drawn  in  bulk  for  periods  of  days, 
usually  ten,  except  the  fresh  meat,  which  is  delivered  on  certain  days 
by  the  contractor,  and  fresh  bread,  which  is  drawn  daily.  The  super- 
vision of  the  company  mess  and  the  management  of  the  use  of  the 
rations  are  within  the  province  of  the  company  commander,  and  are 
by  no  means  his  least  important  duties. 

The  ration  of  the  United  States  army  is  the  most  liberal  and 
diversified  of  any  in  the  world.^  Each  soldier  is  entitled  to  a  per  diem 
allowance  as  follows : — 


^  A  new  ration  order,  issued  by  the  War  Department  April  3,  1908,  mate- 
rially improves  the  already  excellent  U.  S.  ration.  The  allowances  of  the 
standard  meat,  bread,  and  vegetable  components  are  not  greatly  changed,  but 
the  selective  articles  are  more  diversified,  giving  greater  latitude  to  issviing 
and  purchasing  officers,  and  being  adapted  to  diff'erent  markets  and  conditions 
of  service.  Salt  pork  and  salt  beef  have  been  stricken  from  the  list.  Canned 
meats  are  allowed  when  impracticable  to  furnish  fresh.  Turkey  and  chicken 
are  allowed  on  national  holidays.  Half  an  ounce  of  butter  or  oleomargarine 
is  added  to  the  ration,  and  a  like  amount  of  evaporated  cream  for  the  soldier's 
coffee.  The  vegetable  ration  is  increased  to  20  ounces.  There  are  some  other 
minor  changes,  and,  in  addition  to  the  usvial  or  "garrison  ration,"  the  allow- 
ances to  be  issued  under  special  conditions  are  listed  at  length,  as  in  the  "field 
ration,"  the  "haversack  ration,"  the  "travel  ration,"  the  "emergency  ration," 
and  the  "Filipino  ration"  for  the  use  of  the  native  scouts  in  the  Philippine 
Islands. 

The  whole  order  is  too  long  to  insert  in  a  short  chapter  on  military 
hygiene,  but  all  the  really  important  changes  are  here  given. 


THE  FOOD  OF  THE  SOLDIER.  271 

Table  XXXIII. 

Meat  Components. 

Fresh    beef    20  oz. 

Or  fresh  mutton    20  oz. 

Or    bacon    12  oz. 

Or  pork    12  oz. 

Or  salt  beef 22  oz. 

Or  dried  fish    (cod)    14  oz. 

Or  fresh  fish    (cod  whole)    18  oz. 

Or  pickled  fish    (mackerel )    18  oz. 

Or  canned  fish    ( salmon )     16  oz. 

Bread  Components. 

Flour    18  oz. 

Or  soft  bread   18  oz. 

Or  hard  bread    16  oz. 

Or   corn   meal    20  oz. 

Vegetables  and  Miscellaneous. 

Potatoes    16  oz. 

Or  potatoes  80  jjer  cent,  and  onions  20  per  cent 16  oz. 

Or  potatoes  70  per  cent,  and  canned  tomatoes  30  per  cent. .      16  oz. 

Dried  fruits    (various)    2  oz. 

Sugar    2%  oz. 

Or  molasses   i%5  gill. 

Or  cane  syrup   i%5  gill. 

Coffee    ( green )     1%  oz. 

Or  coif ee    ( roasted )    1%5  oz. 

Or  tea   (green  or  black)    %g  oz. 

Vinegar     ^^5  gill. 

Salt    i%5  oz. 

Pepper     1^5  oz. 

Baking  powder  ( in  field  only)    i%5  oz. 

Soap    i%5  oz. 

Candles   %5  oz. 

The  nutritive  value  of  a  ration,  of  course,  varies  greatly,  accord- 
ing to  the  choice  made  from  the  selective  articles  in  the  foregoing 
list. 

The  most  nutritive  combination  that  a  soldier  can  get  in  any  one 
day  consists  of  61  ounces  of  food,  containing,  by  metric  weight,  97.79 
grams  of  fat,  600.74  grams  carbohydrate,  164.27  grams  proteids,  with 
a  total  fuel  value  of  4061  calories.  If  the  selection  is  made  from  the 
least  nutritive  articles  of  the  ration,  a  soldier  may  receive  food  allow- 
ance for  one  day  of  as  low  a  value  as  2321  calories. 

The  field  ration  for  service  in  campaign  consists  of  bacon,  hard 
bread,  beans,  dried  fruit,  sugar,  coffee,  etc.,  with  fresh  vegetables 
when  obtainable.  It  has  a  value,  even  without  the  vegetables,  of  4448 
calories. 

The  German  army  issues  rations  of  the  following  values 
(Atwater)  : — 


272  TEXT-BOOK  OF  HYGIENE. 

German   ration,   peace   footing 2800  calories. 

"  ordinary  war  footing   3095 

"  extraordinary  war   footing 3985         " 

and  the  fuel  value  of  the  diets  of  men  performing  hard  labor  in  civil 
life  have  been  estimated  as  follows : — 

Active  muscular  labor,  Atwater    (American) 4060  calories. 

Men  at  hard  work,  Voit  (German  standard) 3370         " 

Active  laborers,  Playfair    (English  standard) 3630         " 

The  ration  of  the  United  States  army  is  thus  seen  to  be  superior 
to  the  highest  German  ration,  and  to  equal  or  exceed  the  accepted 
standard  diet  of  working  men  in  civil  life. 

In  Alaska  the  already  liberal  army  ration  is  increased  still  fur- 
ther;  vegetables  by  one-half,  bacon  one-third. 

In  the  Philippine  Islands  the  regular  ration  is  issued,  and 
although  the  question  of  a  special  diet  possibly  better  adapted  for 
tropical  climates  has  been  much  discussed,  the  consensus  of  opinion 
of  officers,  both  staff  and  line,  is  against  changing  an  allowance  which 
has  proved  so  satisfactory. 

Each  article  of  the  ration  has  a  fixed  money  value,  which  may  be 
drawn  instead  of  some  of  the  articles,  and  expended  for  the  purchase 
of  food  not  in  the  ration. 

The  money  so  acquired  becomes  a  part  of  the  ^'company  fund," 
along  with  money  received  as  the  organization's  share  of  profits  of  the 
post  exchange,  the  post  bakery,  etc.  With  a  company  fund  judiciously 
expended,  and  with  extra  vegetables  from  gardens  cultivated  at  the 
station,  organizations  in  the  United  States  army  generally  fare  excel- 
lently. Eecent  improvements  in  field  cooking-ranges  and  ovens  make  it 
now  possible  to  serve  as  good  meals  in  stationary  camps  as  in  permanent 
posts.  Much  of  the  sickness  and  consequent  inefficiency  of  hastily- 
raised  bodies  of  troops  is  due  to  lack  of  knowledge  in  drawing,  man- 
aging, and  cooking  the  ration.  No  training  is,  therefore,  more  valu- 
able for  organizations  of  the  National  Guard  that  that  received  in 
the  summer  camps,  where,  under  army  regulations,  they  assume  the 
entire  management  of  their  own  subsistence.  Company  cooks  are  now 
very  well  paid,  and  properly  so,  as  on  their  efficiency  the  health  of  the 
command  very  largely  depends. 

4 THE  CLOTHING  OF  THE  SOLDIER. 

With  due  regard  to  economy,  the  uniform  of  the  soldier  must  be 
well  made  and  of  good  material.  In  the  United  States  army,  the  blue 
uniform  with  brass  buttons  is  now  only  used  in  garrison  and  for  dress 


.    THE  CLOTHING  OF  THE  SOLDIER.  273 

purposes.  In  common  with  most  of  the  large  foreign  nations,  and 
owing  to  the  great  range  of  modern  firearms,  a  color  inconspicuous 
and  harmonizing  with  the  landscape  has  been  adopted  for  field  work. 
To  an  enemy  armed  with  modem  rifle,  using  smokeless  powder,  troops 
uniformed  in  colors  contrasting  strongly  with  their  surroundings  offer 
a  splendid  target  and  are  at  a  great  disadvantage.  Even  the  glint 
of  sunlight  on  polished  buttons  or  weapons  at  a  distance  of  several 
miles  may  attract  the  enemy's  attention  and  result  in  increased  mor- 
tality or  strategical  failure.  The  present  field  uniform  is  of  an  olive- 
drab  or  khaki  color  with  buttons  and  metallic  ornaments  in  bronze. 
It  is  made  in  different  weights,  for  temperate,  arctic,  and  tropical  cli- 
mates, and  does  not  easily  show  the  effects  of  wear. 

Underclothing,  head-covering,  and  foot-gear  are  of  good  quality, 
much  improvement  having  been  made  in  the  shoes  furnished  by  the 
Quartermaster's  Department.  With  infantry  the  care  of  the  feet  is 
a  paramount  consideration;  well-fitting  shoes  and  stockings  are,, 
therefore,  of  the  utmost  importance. 

The  field  uniform  may  be  rendered  tolerably  waterproof  by  lano- 
lin or  one  of  the  other  modern  processes,  afid  this  is  required  by  regu- 
lation. For  protection  against  heavy  rains  and  for  use  when  sleep- 
ing on  the  damp  ground,  the  soldier  is  provided  with  a  rubber  poncho, 
or  blanket. 

So  much  fault  was  found  with  the  method  of  carrying  the  blank- 
ets, extra  clothing,  etc.,  in  a  knapsack  strapped  on  the  back,  and  also 
with  the  very  heavy  cartridge  belt  around  the  waist,  that  a  radical 
change  has  been  found  necessary  in  the  "heavy  marching  order" 
equipment. 

An  ammunition-belt  is  still  used  around  the  waist,  but  is  sus- 
pended by  straps  from  the  shoulders.  Additional  ammunition,  when 
necessary  in  field  service,  is  carried  in  a  '^Dandolier"  worn  diagonally 
across  the  body.  To  the  suspending  straps  are  attached  the  canteen, 
filled  with  water,  and  the  haversack,  containing  rations  and  mess- 
implements.  Blankets,  poncho,  extra  clothing,  etc.,  are  worn  in  a 
roll  over  the  shoulder.  The  total  weight  which  must  be  carried  by  a 
soldier  in  heavy  marching  order,  including  his  clothing,  is  about  70 
pounds,  a  load  far  too  heavy  to  allow  celerity  of  movement,  and  prob- 
ably distinctly  injurious  to  health.  An  ordinary  day's  march  or  two 
may  be  made  witli  fnll  equipment  without  undue  fatigue,  especially 
if  the  destination  is  a  camp  of  some  permanence,  where  the  troops 
may  rest  several  days.  In  very  active  service  a  reduction  in  the 
weight  of  the  equipment  may  l)e  rec|nired  and  must  first  fall  upon  the 

18 


274  TEXT-BOOK  OF  HYGIENE. 

extra  clothing  carried  in  the  bhmket  roll.  By  discarding  overcoat^ 
extra  clothing,  one  blanket,  and  either  the  rubber  poncho  or  shelter- 
tent  half,  the  roll  is  brought  down  to  its  lowest  limit,  the  total  weight 
carried  being  then  below  50  pounds.  The  present  method  of  adjust- 
ing the  load  of  the  foot  soldier  is  a  great  advance  on  the  former  way, 
and  allows  even  the  full  equipment  to  be  carried  with  much  less 
fatigue  than  before. 

5 THE   DWELLING   OF   THE   SOLDIER. 

At  permanent  military  stations  the  troops  are  housed  in  bar- 
racks— buildings  either  of  one  or  two  stories,  constructed  of  stone, 
brick,  or  wood.  A  barrack  for  a  single  organization  should  contain 
large  dormitories  or  squad-rooms,  suitable  bed-rooms  for  non-commis- 
sioned officers  and  the  cooks,  a  large  recreation-  or  day-  room,  kitchen, 
store-room,  lavatory,  and  an  office  for  the  company  commander  and 
the  first  sergeant.  In  the  United  States  army,  the  barracks  con- 
structed in  recent  years  leave  little  to  be  desired,  from  the  sanitarian's 
standpoint.  At  some  of  the  older  stations,  buildings  originally  hastily 
or  cheaply  constructed  have  been  added  to  or  altered  from  year  to  year, 
and  are,  in  consequence,  more  or  less  unfitted  for  military  occupancy. 
Such  posts,  however,  are  either  being  gradually  abandoned  or  else, 
it  having  been  decided  that  the  location  is  to  be  permanent,  entirely 
new  buildings  are  in  course  of  construction  or  provided  for.  There  is 
no  single  accepted  model  in  the  United  States  army  for  barracks.  A 
number  of  plans  have  been  approved  for  buildings  of  various  mate- 
rial and  design. 

The  use  of  the  buildings,  whether  for  infantry,  cavalry,  or  ar- 
tillery, the  climate  and  soil  of  the  proposed  location,  the  cost  and 
availability  of  material,  must  all  be  taken  into  consideration  in  so 
large  a  countrv  as  the  United  States.  Some  of  the  modern  barracks 
are  douljle  and  house  two  organizations,  but  single  barracks  present 
so  many  advantages  that  they  have  been  very  wisely  adopted.  For  the 
proper  location  of  barracks,  a  dry  and  well-drained  site  is  required, 
with  exposure  on  all  sides  to  sunlight  and  air.  The  building  materials 
should  be  the  best  of  their  kind,  and  especial  care  taken  to  avoid  damp- 
ness. A  dry  cellar  nnder  the  whole  building,  when  the  nature  of  the 
soil  permits,  is  a  great  advantage.  In  tropical  countries  the  first 
floor  should  be  raised  several  feet  from  the  ground,  to  permit  a  free 
circulation  of  air  beneath  the  building.  Ample  window-space  and 
broad  verandas  are  also  important  features  in  hot  climates,  where  the 
soldier's  life  is  passed  almost  entirely  in  the  open  air. 

Ventilation   in  the  tropics  presents  no  difficulties,  but   in  cold 


THE  DWELLING  OF  THE  SOLDIER.  275 

climates  the  dormitories  of  soldiers  are  apt  to  be  either  imperfectly 
heated  or  badly  ventilated. 

The  minimum  initial  air-space  per  man  should  never  be  below 
600  cubic  feet,  and  this  amount  is  not  enough  unless  the  means 
of  ventilation  are  exceptionally  good.  One  thousand  cubic  feet  should 
be  looked  upon  as  the  ideal  allowance  per  man,  and  approached  as 
nearly  as  economy  will  permit  in  the  construction  of  new  barracks. 
Each  bed  should  also  be  allowed  a  minimum  floor-space  of  50  square 
feet.  In  the  construction  of  barracks  the  same  rules  apply  as  in  the 
building  of  any  habitation  intended  for  the  use  of  a  large  number  of 
occupants. 

Wood  is  to  be  avoided  as  far  as  possible,  and  fire-proof  material 
substituted. 

Floors  should  be  of  hard  wood,  tongued  and  grooved,  and  laid 
upon  iron  beams  and  cement.  No  wood  should  enter  in  the  construc- 
tion of  the  walls,  the  inside  finish  must  be  smooth,  and  all  corners 
rounded. 

Plumbing  must  be  exposed  throughout  its  course,  and  it  is  a  good 
plan  to  have  the  lavatory  and  water-closets  in  a  detached  structure 
reached  by  a  covered  way,  although  when  properly  constructed  and 
cared  for  there  is  no  great  objection  to  their  location  in  the  base- 
ment. 

In  France,  barracks  built  according  to  the  designs  of  M.  Toi- 
let have  proved  very  satisfactory,  but  seem  not  to  have  been  univer- 
sally adopted  on  account  of  expense.  These  are  built  on  the  pavilion 
plan;  the  first  floor  is  elevated  above  the  ground,  on  which  a  layer 
of  cement  has  been  placed.  The  walls  are  double,  with  air-space  be- 
tween, and  the  materials  fire-proof.  They  are  said  to  be  very  dry,  well 
ventilated,  and  easily  heated.  In  the  British  army,  pavilion  barracks 
of  simple  construction  are  also  much  used.  A  pure  and  simple  water- 
supply  and  perfect  disposal  of  excreta  and  wastes  are,  of  course,  ab- 
solutely essential  to  health  of  troops  in  garrison. 

At  some  sea-coast  forts.  United  States  troops  still  inhabit  case- 
mates, but  it  is  likely  that  in  a  few  years  the  last  of  such  extremely 
unhygienic  quarters  will  be  abandoned.  Casemates  are  damp,  dark, 
and  badly  ventilated,  and  the  inhabitants  are  apt  to  suffer  from  rheu- 
matism and  troubles  of  the  respiratory  organs. 

On  the  march  and  in  camp  the  soldier  is  sheltered  in  tents,  of 
which  the  simplest  form  is  the  shelter-tent.  Each  soldier  has  as  a 
part  of  his  personal  equipment  one  shelter-half  and  a  light,  jointed 
polo.  By  buttoning  together  their  two  pieces  a  small  tent  is  formed, 
beneath  which  two  men  can  crawl  and  keep  themselves  and  equipments 


276  TEXT-BOOK  OF  HYGIENE. 

dry,  except  in  driving  rain-storms.  For  expeditions  when  camp  is 
made  every  night,  it  is  extremely  useful,  but  it  affords  only  a  slight 
protection  in  very  inclement  weather  or  in  extremely  cold  climates. 

The  conical  wall-tent  now  used  is  a  modification  of  the  old  Sibley 
tent.  It  is  circular,  with  a  perpendicular  wall  three  feet  in  height, 
surmounted  by  a  cone  open  at  the  top.  The  top  may  be  covered  in 
whole  or  in  part  by  a  canvas  hood,  which  prevents  the  entrance  of 
rain,  but  which  can  be  opened  for  ventilation.  There  is  a  single  cen- 
tral pole  standing  upon  an  iron  tripod,  between  the  legs  of  which  a 
stove  may  be  placed  in  cold  weather. 

This  tent  is  economical,  protects  well  from  even  driving  rain, 
and  is  especially  comfortable  for  field  work  in  winter. 

The  floor-space  is  213  square  feet,  and  its  capacity  1450  cubic 
feet. 

According  to  the  strict  letter  of  the  regulations,  20  foot-soldiers, 
or  17  cavalrymen  with  their  saddles,  etc.,  are  supposed  to  occupy  one 
tent.  Not  more  than  half  this  number  can,  however,  be  comfortably 
housed,  and,  as  a  matter  of  fact,  the  tentage  issued  to  a  command 
is  never  so  strictly  limited.  Objections  to  the  conical  tent  are  that 
it  is  very  uncomfortable  in  hot  weather,  and  that  the  part  of  the  floor- 
space  on  which  a  full-grown  man  may  walk  erect  is  very  limited. 

The  common  or  "A"  tent  is  oblong,  has  a  wall  of  2  feet,  is  6 
feet  10  inches  in  height,  and  its  floor-space  is  57  square  feet.  Its 
capacity  is  only  250  square  feet,  and  the  ridiculously  excessive  num- 
ber of  six  infantrymen  or  four  mounted  men  is  assigned  to  it  by  regu- 
lation. In  a  permanent  camp,  two  men  only  can  be  perfectly  comfort- 
able in  this  tent,  but  they  may  be  made  exceedingly  so,  as  there  is 
ample  space  for  their  field  cots  and  all  their  equipments. 

The  officers'  wall-tent  is  very  comfortable  for  two  occupants,  as 
it  is  much  larger  than  the  common  tent,  and  is  provided  with  a 
canvas  fly  or  second  roof,  which  protects  perfectly  from  rain  and 
makes  the  tent  much  cooler  in  hot  weather. 

The  hospital  tent  is  the  largest  and  by  far  the  most  comfortable 
tent  used  in  the  army.  It  is  a  Avall-tent  with  a  fly,  and  it  opens  at 
both  ends,  so  that  several  tents  may  be  joined  to  make  a  ward  for  the 
sick.  The  tent  is  14  by  15  feet  floor-space,  and  12  feet  high,  accom- 
modating very  comfortably  six  patients  and  their  cots.  Hospital 
tents,  though  intended  only  for  the  sick,  have  been  sometimes  issued 
to  troops  in  more  or  less  permanent  camj)s  in  the  tropics.  When 
floored  and  framed,  the  occupants  are  as  well  off  as  when  in  barracks. 

All  tents  should  be  properly  ditched  to  prevent  flooding  from 
rain,  and  they  should  be  frequently  struck  and  exposed,  inside  out, 


SANITARY  CARE  OF  CAMPS.  277 

to  the  sun-light.  The  ground  covered  also  must  be  occasionally 
cleaned  and  sunned.  Movable  floors  and  frames  for  tents  increase 
very  much  the  comfort  of  camp  life^,  and  should  always  be  constructed 
in  camps  of  any  permanence. 

The  interior  of  a  tent  is  apt  to  become  stuffy  and  damp,  so  that 
the  walls  should  always  be  kept  elevated  in  good  weather  during  the 
daytime,  allowing  the  greatest  possible  circulation  of  air. 

When  camps  are  to  be  occupied  for  many  months,  especially 
in  winter,  it  is  always  advisable,  on  the  score  of  economy  as  well  as 
health  and  comfort,  to  shelter  the  soldiers  in  huts  or  cabins  instead 
of  tents.  Huts  may  be  constructed  of  logs  plastered  with  mud,  or 
roughly-dressed  lumber  lined  and  roofed  with  canvas.  During  the 
Spanish-American  war,  several  large  general  hospitals  on  the  pavilion 
plan  were  put  up,  for  temporary  use,  of  unpainted  wood  covered 
with  tar-paper.  There  are  in  the  market  also  several  patterns  of 
portable  dwellings,  which  can  be  taken  apart  and  shipped  in  packages 
of  convenient  size,  portions  of  the  floors  and  walls  being  used  for  the 
packing  boxes.  It  is  possible  that  for  armies  of  occupation  such  mov- 
able houses  may  prove  practicable  and  economical. 

6 SANITARY   CARE    OF   CAMPS. 

Sanitation  in  well-built  posts  is  a  simple  matter  enough,  merely 
requiring  that  existing  excellent  conditions  be  maintained.  In  camp 
life  the  health  of  the  troops  depends  on  most  minute  attention  being 
given  to  small  things.  Military  discipline  is  at  the  bottom  of  good 
hygiene,  and  the  custom  of  trained  soldiers  to  keep  every  article  in 
its  place,  and  always  ready  for  inspection,  is  a  powerful  factor  towards 
preserving  their  health.  All  rubbish  must  be  daily  removed  and 
burned.  Kitchen  garbage  and  fragments  of  food  from  the  mess  must 
be  deposited  in  covered  receptacles  periodically  emptied  and  cleaned. 
The  ground  around  the  tents  is  to  be  kept  scrupulously  clean,  and  to 
this  end  it  is  better  that  all  shrubbery  be  cleared  away,  although 
shade-trees  should  not  be  harmed  nor  grass  disturbed.  Waste  mate- 
rial must  never  be  dumped  near  the  camp ;  if  not  destroyed,  it  must 
be  carried  far  away.  The  camp  kitchens  must  be  sheltered  from 
rain,  and  the  food  screened  from  flies  and  dust.  A  pure  water-supply 
having  been  obtained,  the  source,  the  receptacles,  and  the  drinking 
vessels  must  be  kept  uncontaminated.  The  proper  disposal  of  excreta 
in  a  large  camp  is  a  most  important  subject,  and  often  presents  many 
flifficiilties.  The  simplest  method  is  to  dig  latrine  pits  for  each  or- 
ganization, and  cover  the  excreta  therein,  at.  frequent  intervals,  with 
some  of  the  excavated  earth:   but  most  medical  officers  now  condemn 


278  TEXT-BOOK  OF  HYGIENE. 

the  use  of  the  privy  pit  for  any  but  marching  commands,  or  camps 
of  very  short  duration.  Unless  there  is  a  constant  watch  kept,  some 
excreta  is  always  exposed  long  enough  to  attract  swarms  of  flies,  which 
afterward  contaminate  food  in  the  kitchens  and  at  the  mess.  The 
earth,  unless  perfectly  dry,  does  not  deodorize  efficiently,  and  if  the 
ground-water  is  high  the  pits  cannot  be  made  of  sufficient  depth.  The 
use  of  quicklime  in  and  around  the  pits  is  advocated,  or,  better  still, 
they  may  be  burned  out  every  day  with  dry  grass  or  leaves  saturated 
with  kerosene.  A  sanitary  field  latrine  authorized  by  the  War  De- 
partment in  1899,  and  since  used  at  many  permanent  camps,  has 
proved  so  satisfactory  that  its  use  to  the  exclusion  of  any  other 
would  seem  ahvays  advisable.  The  latrine  consists  of  a  trough  made 
of  stout  galvanized  iron  14  feet  long,  32  inches  wide  at  the  top, 
parabolic  in  cross-section,  and  with  a  maximum  depth  of  18  inches. 
This  is  set  in  a  wooden  frame,  used  as  a  crate  in  transportation.  One 
end  of  the  trough  is  elevated  4  inches  from  the  level.  It  is  covered 
by  a  seat  which  may  be  easily  lifted,  and  has  places  for  seven  men. 
The  holes  are  cut  away  so  that  the  seat  cannot  be  soiled  either  in  front 
or  rear,  and  a  slanting  board  arranged  so  that  the  men  cannot  stand 
on  the  seat.  For  use,  the  trough  is  filled  with  water  to  a  depth  of  6 
inches  at  its  lower,  and  2  inches  at  its  upper  end,  and  one-sixth  of  a 
barrel  of  lime  is  mixed  in  daily.  Toilet  paper  must  be  used,  and  the 
contents  of  the  trough  stirred  vigorously  with  a  paddle  three  times 
a  day.  No  other  care  is  necessary,  as  the  apparatus  is  clean,  odorless, 
and  does  not  attract  flies.  A  gutter  to  serve  as  a  urinal,  kept  sprinkled 
with  lime,  is  connected  to  the  trough  at  its  upper  end.  The  latrine 
is  covered  with  a  rough  wooden  shed,  the  dimensions  of  which,  even 
to  the  various  boards  comprising  it,  are  specified  in  orders.  To  empty 
the  trough,  an  odorless  excavator  is  necessary :  a  large,  tight,  barrel- 
shaped  tank  on  wheels,  with  a  powerful  suction-pump.  One  such  ex- 
cavator is  enough  for  many  latrines,  and  the  troughs  must  be 
emptied  daily.  The  mixture  of  milk-of-lime  and  faecal  matter  is 
quite  harmless  and  has  considerable  fertilizing  value.  In  future  no 
large  stationary  camp  should  be  established  in  the  United  States 
without  this  method  of  excreta  disposal,  which  is  the  cheapest  and 
most  effective  yet  devised.  As  there  is  always  difficulty  in  compelling 
the  soldiers  to  use  the  sinks  for  urination,  especially  at  night,  it  is 
advisable  to  have  galvanized  iron  cans  for  urine  placed  at  intervals 
in  the  company  street,  sprinkled  inside  with  lime,  to  be  removed  and 
cleaned  in  the  morning;  otherwise  the  ground  near  the  tents  will  be 
contaminated  with  urine. 


CAMP   DISEASES.  279 

In  camp  sanitation  the  voluntary  cooperation  of  the  soldier  can 
never  be  relied  upon.  Close  inspection,  with  rigid  enforcement  of 
sanitary  rules  by  commanding  officers  and  medical  officers  is  absolutely 
necessary."^ 

7 CAMP    DISEASES. 

When  the  causes  of  disability  and  death  in  the  military  service 
are  looked  into,  it  is  found  that  disease  is  a  far  greater  factor  in 
both,  than  wounds  and  injuries.  In  even  the  bloodiest  wars  the 
total  number  killed  outright  or  dying  from  wounds  never  equals  the 
number   dying  from   sickness. 

Under  the  name  of  "camp  diseases"  may  be  included  all  the 
maladies  to  which  soldiers  are  especially  liable  in  field-work  or  war. 
All  of  these  exist  in  civil  life,  but  the  conditions  of  camp  life  are 
particularly  favorable  to  their  widespread  prevalence. 

Dysentery  and  Diarrhea. — Troops  in  campaign  have  always  been 
especially  subject  to  dysentery  and  diarrhea.  In  the  civil  war  about 
one-fourth  of  all  deaths  in  the  army  were  from  these  two  diseases. 
Even  now,  with  the  many  advances  made  in  medical  knowledge,  and 
especially  in  military  hygiene,  intestinal  diseases  rank  first  in  the 
United  States  army  as  causes  of  disability  and  death.  In  1903,  for 
every  1000  men  there  were  290.61  admissions  and  2.53  deaths  from 
intestinal  complaints.     In  actual  war  the  rates  greatly  increase. 

The  causes  of  intestinal  troubles  in  trcops  may  be  summed  up 
as  impure  water,  badly  cooked  food,  exposure  to  wet  and  cold,  and 
lowered  vitality  due  to  other  diseases,  such  as  malaria. 

Among  troops  in  the  tropics  the  most  serious  disease  of  this 
nature  is  dysentery,  due  to  the  presence  of  an  animal  organism,  the 
Ameba  dysenteric,  in  the  intestines.  The  disease  is  generally  insidi- 
ous in  its  approach  and  exceedingly  difficult  to  cure.  Not  only  has  it 
caused  the  loss  of  many  valuable  lives  in  the  service,  but  numbers 
of  soldiers  have  been  discharged  for  disability,  as  incnrable,  to  live 
lives  of  semi-invalidism  and  probably  to  die  finally  of  exhaustion,  or 
from  intercurrent  attacks  of  diseases  which  the  weakened  bodies  are 
unable  to  resist.     Of  dysentery  and  much  of  the  diarrhea,  impure 

2  The  field  latrine  described  in  Jie  text  has  fulfilled  all  that  was  expected 
of  it.  but  since  this  chapter  was  written  it  has  been  largely  superseded  by  the 
"McC'all"  incinerator,  which  received  a  thorough  test  at  the  camp  of  U.  S. 
troops  at  the  Jamestown  Exposition.  This  device  is  a  privy  and  incinerator 
combined.  The  fecal  matter  and  urine  are  totally  consumed  by  fire  on  the 
spot  where  they  have  been  deposited,  necessitating  no  handling  and  but  little 
daily  labor.  The  apparatus  is  in  two  sections,  one  of  which  is  in  use  as  a 
privy  while  the  other  acts  as  an  incinerator.  The  process  of  incineration  is 
achieved  without  any  noxious  gases  being  given  off. 


280  TEXT-BOOK  OF  HYGIENE. 

water  is  the  principal  and  possibly  the  only  cause,  and  in  the  Philip- 
pine Islands  the  one  sanitary  rule  exceeding  all  others  in  impor- 
tance, and  most  insisted  npon,  is  the  purification,  by  boiling  or  distil- 
lation, of  all  drinking  water  furnished  to  the  troops. 

It  is  practically  impossible  to  prevent  individual  soldiers  absent 
from  camp  or  post,  or  during  the  march,  from  slaking  their  thirst 
at  the  nearest  source,  and,  therefore,  dysentery  still  claims  its  quota 
of  victims  annually.  When  to  impure  water  are  added  bad  food,  un- 
sanitary surroundings,  and  reduced  vitality,  a  form  of  acute  dysentery 
may,  assuming  epidemic  proportions,  sweep  through  the  camps  with 
the  virulence  of  cholera.  This  variety  is  not  amebic,  but  is  due  to 
the  Bacillus  dysenterias  of  Shiga  and  sometimes  possibly  to  other 
bacterial  organisms.  In  civil  life  it  occurs  in  overcrowded  prisons 
and  asylums,  causing  great  mortality.  A  very  important  feature  in 
the  prevention  of  dysentery  and  the  more  serious  forms  of  diarrhea 
among  troops  is  prompt  attention  to  the  treatment  of  every  slight  di- 
gestive trouble,  both  by  proper  diet  and  medicines,  for  it  often  happens 
that  an  attack  of  acute  intestinal  indigestion,  with  simple  diarrhea, 
is  the  starting-point  for  chronic  diarrhea  or  amebic  dysentery. 
The  use  of  a  woolen  abdominal  band  when  sleeping  in  the  field  is 
to  be  recommended.  In  the  intense  heat  of  the  tropics  there  is  no 
need  to  undergo  the  discomfort  of  wearing  the  band  in  the  daytime, 
but  at  night  the  abdomen  may  easily  become  chilled,  and  the  flannel 
binder  is  both  comfortable  and  useful  as  a  preventive  measure. 

Malarial  Fevers. — Xext  to  intestinal  diseases,  malarial  fevers  and 
the  resulting  cachexia  are  accountable  for  the  largest  percentage  of 
sickness  in  the  United  States  army.  Troops  serving  in  the  tropics 
suffer  greatly  from  malaria,  and  when  a  command  is  once  thoroughly 
poisoned  with  the  malignant  form  of  the  disease  it  is  practically 
destroj^ed,  as  far  as  its  usefulness  in  war  is  concerned. 

In  the  Spanish-American  war  the  Fifth  Corps,  nearly  all  regu- 
lars and  the  flower  of  the  army,  was,  as  a  result  of  the  operations 
in  front  of  Santigo  de  Cuba,  so  affected  with  pernicious  malaria  that 
nearly  all  officers  and  enlisted  men  returned  to  the  United  States 
complete  physical  wrecks,  necessitating  either  long  furloughs  or  dis- 
charges for  disability. 

The  discovery  of  recent  years,  that  malarial  fevers  are  caused 
by  several  varieties  of  animal  parasites  in  the  blood  and  are  con- 
Yejed.  from  man  to  man  by  the  bite  of  certain  infected  mosquitoes 
of  the  family  Anopheles,  has  led  to  methods  of  prevention  founded 
upon  positive  knowledge,  instead  of  the  former  vague  ideas  of  infec- 


CAMP   DISEASES.  281 

tion  as  due  to  noxious  emanations  from  swamps,  exposure  to  the 
night  air,  etc. 

In  countries  where  malaria  is  prevalent,  troops  must  be  protected 
as  far  as  practicable  from  the  attacks  of  mosquitoes,  by  the  use  of 
screers  and  netting.  Swampy  and  low-lying  camps  are  avoided  when 
possible,  not  on  account  of  any  toxic  properties  in  marsh  air,  but  on 
account  of  the  well-known  prevalence  of  mosquitoes  in  such  places. 
In  tropical  countries  inhabited  by  more  or  less  uncivilized  races,  a 
safe  distance  should  always  be  allowed  between  the  camp  and  the 
native  village.  The  inhabitants  are  sure  to  be  more  or  less  infected 
with  a  chronic  form  of  malaria.  They  have,  it  is  true,  acquired  a 
certain  tolerance  of  the  disease,  and  as  they  are  not  usually  very  sensi- 
tive to  the  annoyance  of  bites  of  insects,  they  never  use  screens. 

The  mosquitoes  infesting  their  huts  are  exceedingly  apt  to  harbor 
the  malarial  parasites,  and  a  single  night's  camp  made  in  a  native 
village  by  a  party  of  white  men,  unprotected  by  mosquito-bars,  is 
often  followed  by  an  outbreak  of  fever.  It  is  generary  thought  that 
a  half  mile  is  a  safe  distance  to  allow  between  the  village  and  the 
camp.  At  military  posts,  cantonments,  or  permanent  camps,  a  general 
war  of  extermination  should  also  be  waged  against  the  insects.  As 
the  eggs  of  mosquitoes  are  deposited  in  standing  water  and  the  larvae 
live  therein,  all  swamps,  ponds,  and  puddles  should  be  drained,  or, 
when  this  is  impracticable,  the  surface  of  the  water  should  be  kept 
covered  with  a  thin  film  of  petroleum,  renewed  about  every  two 
weeks.  Wells,  cisterns,  and  receptacles  for  drinking-water  must  be 
covered  with  wire  screens.  The  fertility  of  the  female  mosquito 
is  so  great  that  thousands  of  the  insects  may  be  developed  in  cast-off 
tin  cans,  broken  pots  and  bottles,  which  have  collected  rain-water 
and  which  are  so  universally  found  on  badly-kept  premises.  Such 
rubbish  must,  therefore,  not  be  permitted. 

Malaria  can  undoubtedly  be  banished  from  a  community  when 
each  householder  is  held  responsible  for  the  maintenance  of  conditions 
unfavorable  to  the  growth  of  mosquitoes  on  his  premises. 

Sometimes,  as  in  many  places  in  the  Philippines,  mosquito- 
destruction  on  a  large  scale  is  entirely  impracticable,  the  submerged 
rice-fields  and  thick  Jungles  presenting  too  many  breeding  places  for 
the  insects.  For  instance,  in  palm-trees,  at  the  junction  of  each 
great  leaf  with  the  stem  there  is  a  hollow  space  generally  containing 
several  quarts  of  water,  each  of  which  spaces  may  be  the  breeding- 
place  of  myriads  of  mosquitoes.     Under  such  conditions,  of  course. 


282  TEXT-BOOK  OF  HYGIENE. 

preventive  measures  must  largely  consist  in  protection  of  the  indi- 
vidual, rather  than  in  insect-destruction.  Malarial  fevers  are  dimin- 
ishing rapidly  in  the  United  States  army  as  a  result  of  our  present 
clear  understanding  of  cause  and  effect. 

Yellow  Fever. — The  demonstration  of  the  fact  that  yellow  fever 
is  also  transmitted  by  mosquitoes,  of  the  family  Stegomyia,  has  taken 
it  from  the  list  of  diseases  which  are  to  be  much  feared  by  armies  in 
the  future. 

The  as  yet  unknown  infective  agent  is  in  the  blood  of  patients 
only  during  the  first  three  days  of  the  attack,  and  a  mosquito  ingest- 
ing the  blood  of  a  patient  during  this  time  does  not  transmit  the 
disease  until  about  twelve  days  have  elapsed.  Yellow  fever  has  never 
been  much  of  a  camp  disease,  but  troops  occupying  cities  on  the  sea- 
coast  in  countries  where  it  prevails  have  sometimes  suffered  terribly. 

The  disease  has  been  entirely  eliminated  in  Cuba  by  screening  the 
patients  during  their  short  infective  period,  and  by  destroying  the 
mosquitoes  in  the  infected  house  and  those  near  by.  There  is  hardly  a 
doubt  but  that  a  little  concerted  effort  on  the  same  lines  in  the  few 
places  where  yellow  fever  now  exists  will  cause  the  complete  extinc- 
tion of  this  disease  in  its  endemic  centers. 

Typhoid  Fever. — This  is  always  a  serious  and  unfortunately  a 
most  common  disease  of  camps.  Pollution  of  the  drinking-water  sup- 
ply by  the  excreta  of  typhoid  patients  is  usually  assigned  as  the  cause. 
While  epidemics  occurring  in  villages  and  cities  are  perhaps  generally 
with  reason  traced  to  an  impure  water-supply,  it  is  very  likely  that  the 
typhoid  fever  of  camps  is  transmitted  from  man  to  man  in  a  much 
more  direct  way.  During  the  Spanish-American  war,  the  camps  of 
volunteer  soldiers  in  the  United  States  were  swept  by  this  disease, 
although  in  many  instances  the  water-supply  was  beyond  suspicion 
of  contamination.  It  being  taken  for  granted  as  a  fact  that  several 
hjindred  men  can  hardly  be  collected  into  a  camp,  anywhere  in  the 
United  States,  without  at  least  one  case  of  typhoid  fever  existing 
among  them  on  arrival,  the  conditions  of  camp  life  will  account  for 
the  spread  of  the  disease.  Unless  the  faecal  discharges  of  all  men 
are  at  once  disinfected  or  removed,  flies  may  carry  infection  from 
excrement  in  the  sinks  to  food  in  the  kitchens.  Soil-pollution  in 
and  around  tents  from  unrecognized  cases  of  typhoid  fever,  and  con- 
tamination by  the  sick  of  clothing,  towels,  utensils,  etc.,  may  in  many 
different  ways  transmit  the  germ  of  the  disease  to  other  soldiers.  The 
board  of  medical  officers  who  studied  the  tj'phoid  fever  in  the  volun- 
teer camps  of  1898  traced,  in  many  companies  and  regiments,  the 
gradual  progress  of  the  disease  from  tent  to  tent,  and  from  man  to 


CAMP   DISEASES.  283 

man.  Preventive  measures  against  typhoid  fever  in  camps  should 
then  include  not  only  furnishing  the  troops  with  pure  w^ater,  but 
also  the  immediate  destruction  or  disinfection  of  all  excreta,  rigid 
protection  of  the  soil  from  contamination,  and  careful  personal 
hygiene. 

Cholera. — The  precautions  against  typhoid  fever  apply  also  to 
Asiatic  cholera.  During  the  recent  severe  epidemic  in  the  Philippine 
Islands,  some  garrisons  were  entirely  free  from  cholera,  although  na- 
tives were  dying  by  hundreds  in  the  immediate  neighborhood.  It  is 
hardly  too  much  to  say  that  nearly  every  case  of  cholera  among  the 
troops  could  be  traced  to  a  violation  of  the  hygienic  ru^es  prepared 
for  the  soldier's  guidance.  Sterilization  of  drinking-water  and  the 
avoidance  of  native  food  and  beverages,  especially  fruits  and  green 
vegetables  eaten  uncooked,  were  the  leading  measures  taken. 

Phthisis. — Phthisis  is  now  a  rare  disease  in  armies,  as  cases  are 
promptly  removed  from  barracks  as  soon  as  recognized,  and  in  the 
United  States  army  are  sent  to  a  special  hospital  at  Fort  Bayard, 
New  Mexico.  Opportunities  for  infecting  others  are  thus  avoided,  and 
the  patients  given  an  excellent  chance  for  recovery  by  suitable  open- 
air  treatment  in  a  good  climate. 

Typhus  fever  and  scurvy  have  not  for  years  figured  in  the  list  of 
camp  diseases.  In  the  light  of  modern  hygienic  knowledge  it  is  not 
likely  that  they  will  again  exist  to  any  extent. 

Venereal  Diseases. — The  most  discouraging  feature  of  the  sick 
report  of  armies  is  the  great  prevalence  of  venereal  disease.  Espe- 
cially in  service  when  troops  come  into  contact  with  a  savage  or  half- 
civilized  race  is  the  large  ratio  of  non-effectiveness  from  this  cause 
particularly  noticeable.  In  places  under  martial  law,  regulation  of 
prostitution,  with  frequent  inspection  of  the  women,  periodical  ex- 
mination  of  the  soldiers,  and  prompt  segregation  of  all  infected  per- 
sons, will  reduce  venereal  disease  to  very  low  limits.  In  times  of 
peace,  and  under  civil  law,  regulation  of  prostitution  does  not  carry 
out  all  the  claims  of  its  advocates.  It  never  reaches  clandestine  vice, 
and  may  even  have  a  tendency  to  encourage  it.  Public  opinion  among 
English-speaking  people  is  so  entirely  antagonistic  to  the  regulation 
and  licensing  of  prostitution,  that  it  is  quite  hopeless  to  advocate  it, 
even  were  it  proved  to  be  much  more  effective  than  the  experience 
of  foreign  nations  seems  to  indicate. 

Frequent  inspections  of  the  soldiers  and  prompt  treatment  in 
hospital,  together  with  suitable  instructions  to  recruits  as  to  the 
dangers  of  venereal  disease,  are  never  to  be  neglected,  although  it 
must  be  confessed  these  are  sadly  inadequate  means  of  prevention. 


QUESTIONS  TO  CHAPTER  X. 

MILITARY  AND  CAMP  HYGIENE. 

What  subjects  may  be  considered  under  this  head?  Why  should  an  army 
be  composed  of  sound  and  healthy  individuals?  Who  should  be  excluded  from 
an  army  or  body  of  troops?  What  is  the  lowest  age  at  which  recruits  should 
be  enlisted  ?  What  the  highest  age  ?  What  should  be  the  minimum  measure- 
ments of  the  recruit?  Who  should  make  the  physical  examination  of  the 
latter  ? 

What  can  be  said  for  the  present  army  ration  of  the  United  States? 
What  besides  insufficient  quantity  and  variety  of  food  may  cause  digestive 
disturbances  and  innutrition  in  camp? 

\Miat  part  of  the  United  States  soldier's  clothing  at  present  is  most 
apt  to  cause  physical  discomfort?  What  change  might  be  made  to  advantage 
in  the  manner  of  carrying  the  extra  clothing?     How  is  it  now  carried? 

What  usually  constitutes  the  dwelling  of  the  soldier?  What  is  a  mili- 
tary barrack,  and  what  is  its  general  plan?  What  is  to  be  said  about  the 
location  of  barrack  lavatories,  kitchens,  and  dining-rooms,  sinks,  and  latrines? 
On  what  kind  of  soil  should  barracks  be  located? 

What  sort  of  tents  are  used  in  the  army?  What  are  the  advantages 
of  the  simple  shelter  tent?  Wbat  may  take  the  place  of  tents  in  winter? 
What  is  of  the  first  imjiortance  in  all  camps,  and  what  is  necessary  to  secure 
this? 

In  actual  war  what  relation  do  the  deaths  from  disease  bear  to  those 
from  injuries  received  in  battle?  What  are  the  most  fatal  diseases  of  camp 
life?  What  are  the  causes  leading  to  this  fact?  What  other  class  of  diseases 
is  especially  apt  to  be  frequent  among  soldiers  ?  What  effect  has  the  mala- 
rial poison  on  those  sick  with  other  diseases?  What  would  lessen  the  preva- 
lence of  malarial  fevers  in  camp-life?  How  may  typhoid  fever  be  propagated 
in  camps  and  garrisons?  What  respiratory  diseases  are  common  in  camps, 
and  to  what  are  they  due?  \Vhat  two  diseases,  formerly  common  in  camp- 
life,  are  now  rare?  What  contagious  diseases  are  especially  associated  with 
the  soldier?     By  what  means  may  their  spread  be  restricted? 


(284) 


CHAPTER  XI. 

MARINE    HYGIENE. 

Marine  Hygiene  may  be  briefly  defined  as  being  a  specially  de- 
veloped branch  of  General  Hygiene.  While  the  ultimate  aims  of  both 
are  identical,  marine  hygiene  differs  from  land  hygiene  in  that  it 
presents  for  our  study  and  investigation  a  series  of  peculiar  environ- 
mental conditions,  under  the  influences  of  which  the  individual 
members  or  communities  of  the  sea-faring  class  are  obliged  to  live 
and  which  are  quite  distinct  from  those  which  would  surround  the 
same  individuals  or  communities  if  they  were  living  on  land.  The 
marine  sanitarian,  therefore,  stands  between  the  sea-faring  man  on 
the  one  hand,  and  his  peculiar  and  quite  artificial  environments  on 
the  other,  endeavoring  to  maintain  and  promote  the  health,  comfort, 
and  happiness  of  the  former  by  preventing  or  modifying,  as  far  as 
it  may  be  within  his  knowledge  and  power,  the  injurious  influences  of 
the  latter. 

In  the  United  States  and  in  several  of  the  European  monarchies 
a  distinction  is  made  between  marine  and  naval  hygiene.  This  dis- 
tinction always  appeared  to  be  more  apparent  than  real,  until,  within 
recent  years,  the  modern  battleship  and  cruiser  were  evolved  and  ap- 
peared on  the  scene.  Since  then  there  can  no  longer  be  any  doubt 
about  the  fact  that  there  is  indeed  a  wide  difference  between  the  influ- 
ences upon  human  life  of  the  conditions  prevailing  on  these  ships  as 
contrasted  with  those  existing  on  merchant  ships.  This  difference  is 
indeed  so  great  that  it  deserves  the  special  attention  and  study  of  the 
hygienist,  and  will  continue  to  receive  them  in  the  future.  Within 
the  limited  space  of  this  article  only  those  conditions  will  be  dis- 
cussed that  prevail  on  both  classes  of  ships  alike. 

HISTORICAL. 

The  seaman,  as  regards  his  original  composition,  his  character 
and  instincts,  as  well  as  other  human  traits,  may  safely  be  said  to  have 
differed  at  no  time  from  any  other  individual  average  member  of  the 
human  family.  The  descriptions  with  regard  to  liis  life  and  character 
that  we  read  about  in  history  are  indicative  more  of  what  can  become 
of  any  normally  constituted  human  being  under  the  educational  influ- 

(285) 


286  TEXT-BOOK  OF  HYGIENE. 

ences  either  of  a  life  of  romance  and  adventure,  or  of  degraded  condi- 
tions and  inhuman  treatment,  or  both  these  combined,  than  they  are  of 
any  more  essential  difference  in  the  original  make-up  of  the  man. 
He  is,  in  other  words,  like  any  other  man,  more  or  less  the  result  of 
the  life  he  leads. 

In  former  times,  when  away  on  long  voyages  in  sailing  ships,  away 
for  long  periods  of  time  from  home  and  friends,  the  seaman  was  often 
at  the  mercy  of  inhuman  and  cruel  masters,  who  exacted  excessive 
work  in  return  for  insufficient  food,  scanty  clothing,  poor  lodging, 
abuse,  and  neglect  when  sick  or  disabled.  The  history  of  those  early 
days  abundantly  shows  how  little  attention,  especially,  was  paid  to 
sanitary  matters;  in  fact,  how  little  was  known  with  regard  to  such 
matters.  No  records  of  ships'  sanitation  were  kept.  Some  of  the 
earliest  recorded  accounts  of  the  medical  treatment  directed  against 
the  diseases  peculiar  to  ships  we  find  in  a  book  published  in  1693  by 
a  Dutch  surgeon  named  Verbriigge,  while  Vrolingh  adds  a  brief  de- 
scription of  the  provisions  that  were  supplied  to  the  men  at  those 
times  and  of  the  scurvy  that  they  suffered  from. 

The  more  important  works  on  marine  hygiene,  in  the  beginning 
of  the  last  century,  were  those  of  Lind,  Kouppe,  Duhamel  de  Monceau, 
Poissonier-Deperrieres,  Smollet,  Blane,  Clark,  and  Meunier.  About 
the  middle  of  the  last  century  the  works  of  Forget,  Fonssagrives,  Mac- 
donald,  Wilson,  Turner,  and  Gihon  came  into  prominence,  and  towards 
the  end  of  the  nineteenth  century  the  quite  advanced  works  of  Eich- 
ard  et  Bodet  and  of  Dr.  xA.rthur  Plumert  appeared.^ 

Instead  of  regular  sanitary  records,  kept  by  medical  officers,  we 
will  have  to  depend  upon  the  fragmentary  accounts  in  ships'  logs, 
kept  by  masters  of  vessels,  for  the  very  earliest  records  we  possess 
with  regard  to  sanitary  matters  on  ship-board.  According  to  these, 
the  ravages  of  disease,  at  times,  must  have  been  positively  appalling. 
Thus,  for  example.  Admiral  Anson,  in  1741,  reports  the  loss,  within 
a  few  weeks,  of  200  men  by  scurvy  alone  out  of  a  complement  of 
600  men;  he  landed  on  Juan  Fernandez  with  but  8  men  able  to  do 
duty.  Geary,  in  1779,  is  said  to  have  had  at  one  time  in  his  squadron 
2400  cases  of  scurvy;  and  Rodney,  in  1780,  once  lost  from  50  to  55 
men  of  the  same  disease  weekly,  out  of  a  complement  of  men  number- 
ing only  2000. 

Ships'  fevers  were  of  the  more  frequent  occurrence  according  to 

^Also  the  following  works  on  Naval  Hygiene:  Noeht,  "Schiffshygiene," 
Berlin,  1905;  Belli,  "Igiene  Navale,"  Rome,  1905;  Couteaud  et  Girard, 
"L'Hygiene  dans  la  marine  de  guerre  moderne,"  Paris,  1905;  "Jan  et  Plante 
Hygiene  navale,"  in  Brouardel  et  Mosny's  "Traite  d'Hygiene,"  1907. 


HISTORICAL.  287 

reports.  Under  this  head  were  summed  up  what  we  would  now 
distinguish  as  typhus,  typhoid,  malarial,  and  other  fevers.  Thus, 
Lind,  among  others,  says  of  a  French  fleet  of  vessels  which,  in  1757, 
was  on  its  way  from  Louisburg  to  Brest :  "This  fleet  was  engaged  in 
transporting  1000  convalescents  from  the  various  hospital  tents  at 
Louisburg  to  Brest.  After  the  sixth  day  out  most  every  one  of  these 
had  died."  Blane,  while  fleet-surgeon  of  40  line-of-battle  ships,  with 
21,608  men,  cruising  in  the  West  Indies  between  1780-1783,  reports 
the  loss  of  3200  men  from  disease  and  but  1148  men  from  the  enemy's 
guns,  and  he  attributes  this  enormous  death-rate  to  bad  quarters,  over- 
crowding, insufficient  ventilation,  poor  food,  and  bad  drinking-water 
combined.  Many  of  the  men,  especially  those  who  were  obliged  to 
work  below,  actually  died  from  suffocation. 

In  the  "Souvenirs  d'  un  Admiral,"  Jurien  de  la  Gravieres,  the 
following  note  by  Admiral  Latouche  was  found:  "The  ships  of  his 
squadron  arrived  at  the  ^Station  du  Nord'  in  the  following  condi- 
tion: The  Cornette,  with  a  complement  of  400  men,  had  thrown  37 
overboard  and  sent  122  to  the  hospital;  the  Necessaire,  out  of  a  com- 
plement of  80  men,  had  thrown  13  overboard  and  sent  21  to  the 
hospital;  the  Theobald  had  thrown  136  into  the  sea  and  landed  129 
in  the  hospitals,  arriving  with  only  35  men  in  all  in  port." 

It  is  said  that  the  men  on  these  ships  were  crowded  together  so 
closely  that  there  was  scarcely  as  much  breathing  space  for  them  as  is 
generally  allowed  a  man  in  his  coffin.  There  was  no  provision  whatever 
made  for  ventilation,  much  less  for  lighting.  The  decks  below  were 
both  foul  and  dark,  so  that  the  human  breath  was  believed  to  be  fatal. 
Often  the  berth-decks  were  used  for  live-stock  for  fresh  meat,  and 
most  of  the  men  and  all  the  sick  were  usually  kept  on  this  deck.  The 
men,  as  a  rule,  were  provided  with  but  one  suit  of  clothes,  and  this  was 
worn  until  it  literally  dropped  off  their  bodies.  The  only  means  they 
had  of  washing  their  clothes  was  to  tow  them  alongside  the  ship  in  the 
sea-water  while  under  way.  The  hammocks,  we  are  told,  were  never 
taken  off  their  hooks,  neither  were  they  scrubbed  or  aired,  and  one 
hammock  often  had  to  serve  for  the  berthing  of  two  men ;  and  these 
conditions  prevailed  on  some  of  the  station-ships  down  to  1856.  The 
care  of  their  persons  was  left  entirely  to  the  men  themselves,  the 
officers  deeming  it  beneath  their  dignity  to  bother  themselves  about 
such  details.  No  drills  of  a  systematic  order  were  performed,  and 
punishment  for  the  slightest  infraction  against  the  prevailing  and 
mostly  cruel  regulations  was  usually  prompt  and  of  the  most  brutal 
nature. 


288  TEXT-BOOK  OF  HYGIENE, 

In  spite  of  the  shining  example  of  Captain  Cook,  who,  during 
his  three-years'  cruise,  between  1772-1775,  lost  but  one  man  of  his 
crew,  through  a  wise  application  of  the  simplest  laws  of  health  and 
humane  treatment  of  his  men,  his  experiences  and  the  lessons  it 
should  have  left  behind  went  almost  entirely  unheeded.  This,  more 
than  anything  else,  shows  that  nothing  short  of  the  strictest  laws 
and  regulations  can  ever  be  depended  upon  to  improve  the  sanitary 
conditions  of  the  seaman,  his  life  and  surroundings.  To  see  that  these 
are  enforced  and  carried  out  is  the  duty  of  the  ship's  sanitarian, 

Finall}^,  the  following  anecdote,  which  is  recorded  as  a  part 
of  the  history  of  those  days,  may  be  cited,  as  illustrating  the  indiffer- 
ence to  sanitary  matters  of  the  then  class  of  masters  of  vessels  who 
held  undisputed  sway.  The  story  is  told  of  an  English  admiral 
who  was  asked  to  stop  his  ship  for  the  purpose  of  picking  up  the 
second  surgeon,  who  had  just  fallen  overboard.  The  admiral  posi- 
tively refused  to  pick  the  man  up,  saying  that  it  was  only  the  ques- 
tion of  a  useless  man  on  board,  anyway. 

MORBIDITY    AND    MORTALITY    OCCURRING    IN    SEAFARING 

PEOPLE. 

Although  it  must,  perhaps,  be  admitted  that  the  encouraging 
results  obtained  in  recent  years  with  regard  to  a  decrease  in  mor- 
bidity and  mortality  rates  among  seafaring  people,  and  which  we  find 
repeatedly  recorded  in  these  days,  are  in  great  part  directly  traceable  to 
the  improvements  made  in  ships'  construction,  yet  it  must,  I  think,  be 
likewise  granted  that,  were  it  not  for  the  great  advances  that  have 
been  made,  more  or  less  simultaneously,  in  scientific  hygiene,  the 
above-mentioned  favorable  results  could  not  have  been  attained. 
Experience,  both  past  and  present,  has  repeatedly  shown  that  with- 
out constant  vigilance  shown  in  the  administration  of  hj^gienic  laws, 
without  constant  sanitary  supervision  of  the  men  on  board  ships,  we 
would  repeat  the  sad  experiences  of  the  past,  in  less  time  than  it  would 
take  to  tell  it,  in  spite  of  iron  ships  that  are  run  by  steam  instead  of 
sail.  The  fact  that  scurvy  and  other  diseases  did  not  come  from  the 
wood  of  which  the  old  ships  were  built,  was  clearly  shown  during  the 
three-years'  cruise  of  Captain  Cook  (1773-75),  and  the  other  fact 
that  these  same  diseases  are  ready  to  recur  on  board  any  of  the  modern 
iron  ships  when  allowed  to  lapse  imder  the  same  unsanitary  condi- 
tions as  used  to  prevail  in  the  old  Avooden  ships  a  hundred  years 
ago,  are  likewise  well  established  by  the  reports  of  scurvy  and  other 
filth-diseases,  known  to  occur  up  to  the  present  day.    To  the  improve- 


MORBIDITY  AND  MORTALITY  IN  SEAFARING  PEOPLE.       289 

ments  made  in  ships'  construction  we  must,  therefore,  add  those  made 
in  experimental  liygiene  and  sanitary  supervision. 

Better  food,  better  water,  more  suitable  wearing  apparel,  more 
light  below  decks,  and,  above  all,  more  and  a  better  quality  of  air, 
these  are  the  direct  results  of  the  work  done  by  hygienists  and  which 
the  seafaring  people  never  again  will  do  without  on  board  their  ships. 
But,  notwithstanding  these  improvements  in  both  ships'  construc- 
tion and  hygienic  living,  there  is  still  enough  left  to  show  that  the 
life  of  the  seaman,  with  regard  to  his  home,  his  clothing,  his  food,  the 
climatic  influences  to  which  he  is  exposed,  his  social  comforts  and 
enjoyments,  are  different  from  those  of  the  rest  of  mankind.  All 
these  more  or  less  abnormal  conditions  of  life  must  still  lead  to  cer- 
tain diseases  other  than  filth-diseases,  that  will  ever  be  peculiar  to 
the  seafaring  class  and  the  causes  of  which  we  must  find  out  and  try 
to  eliminate. 

The  lines  along  which  we  must  proceed  with  our  work  will  be- 
come clear  to  us  from  a  study  of  the  morbidity  and  mortality  rates. 
These  statistics  will  give  us  the  first  needed  information.  They  will 
show  us  not  only  the  nature,  but  also  the  extent,  of  the  inroads  which 
disease  is  making  into  the  seafaring  population,  as  well  as  the  influ- 
ence which  sanitary  regulations  have  had  from  time  to  time  upon  their 
course.  Notwithstanding  the  fact  that  Captain  Cook,  during  his 
long  cruise  of  three  years,  lost  but  one  man  from  his  crew,  by  wisely 
following  out  the  laws  of  hygienic  living  on  board  his  ship,  his  bril- 
liant example  did  not  produce  the  widespread  influence  that  it  should, 
and  was,  apparently,  only  reluctantly  followed.  Among  the  auto- 
cratic masters  of  the  seas  of  those  times,  precepts  were  without  influ- 
ence;   regulations  of  the  strictest  order  alone  produced  any  effect. 

According  to  Blane,  the  annual  mortality  in  the  English  fleet 
in  1780  was  12.5  per  cent.;  in  1811  it  had  gone  down  to  4  per  cent., 
and,  during  the  period  from  1830-64,  it  had  dwindled  down  to  1.3 
per  cent.  This  astounding  diminution  of  the  mortality  rate  of  the 
English  fleet  is  directly  traced  to  a  sanitary  regulation  which  was 
issued  by  the  Admiralty  in  1791,  revised  and  improved  in  1797. 
This  means  an  immense  saving  of  human  lives. 

Very  valuable  statistical  tables  have  l^een  worked  out  for  us  by 
Friedel,  quoted  by  Kulenkampf.  According  to  these  authors,  the 
morbidity  and  mortality  of  the  English  fleet,  during  the  years  1830 
to  18G4,  were  as  follows:  The  mean  annual  strength  of  the  fleet, 
calculated  for  the  entire  period  of  34  years,  was  35,269  men,  among 
whom  occurred,  on  the  average,  121.2  per  cent,  cases  of  sickness;   2.69 

]9 


290 


TEXT-BOOK  OF  HYGIENE. 


per  cent,  of  which  resulted  in  being  invalided  from  the  service  and 
1.33  per  cent.  died.  The  influence  upon  morbidit}^  and  mortality  of 
the  different  stations  is  well  shown  in  the  following  table: — 

Table  XXXIV. 


stations. 

Number  of 
Sick. 

Died. 

Daily  Number 
of  Sicli. 

1.     East  Indies  and  China 

178.8% 

158.0% 

142.2% 

82.3% 

89.3% 

3.13% 
3.39% 
2.0% 

0.74% 
0.45% 

8.88% 
6.58% 
5.83% 

4  8% 
4.38% 

2.     West  Africa 

3.     West  Indies  and  America 

4.  Mail  Service 

5.  Home  Stations 

6.     Australia  

The  relative  percentage  distribution  among  the  more  important 
diseases  may  be  seen  in  table  XXXV : — 

Table  XXXV. 


Diseases. 

Per  Cent, 
of  Mean 
Strength. 

Diseases. 

Per  Cent, 
of  Mean 
Strength. 

Phlegmonous  inflammations  . 
Catarrhs  

23.3 

19.3 

10.9 

10.3 

7.8 

1.8 

0.12 

Variola 

0.15 

Erysipelas 

0.47 

Fevers  ( typhoid  and  malarial ) 

Diarrheas  

Rheumatism  

Tuberculosis 

06 

Pneumonia  and  pleuritis  . . . 
Delirium  potator 

1.7 
0.28 

i  )vsenterv   

Sourvy  

0.1 

Cholera 

In  order  to  show  the  progress  in  sanitation  made  since  that  time, 
it  will  perhaps  suffice  to  quote  some  figures  from  the  more  recent 
report  of  the  Surgeon  General  of  the  United  States  Navy  on  the 
present  state  of  the 

Health  of  the  Navy  and  Marine  Corps  of  the  United  States: — 
During  the  year  1902,  the  average  strength  of  the  active  list  of  the 
Navy  was  31,240.  The  total  niimber  of  admissions  to  the  sick-list,  for 
all  causes,  during  the  year  1902,  was  22,645,  or  76.8  per  cent.  There 
were  18,882  admissions  for  disease  and  3,763  for  injuries.  The  daily 
average  of  patients  was  3.5  per  cent,  of  mean  strength.  The  total 
number  of  sick  days  was  374,466,  or  an  average  of  12.05  sick  days  for 
each  man  in  the  Navy  and  Marine  Corps,  with  an  average  duration  of 
16.53  days'  treatment  for  each  case. 


MORBIDITY  AND  MORTALITY  IN  SEAFARING  PEOPLE. 
Table  XXXVI. 


291 


Classification  of  Diseases 


Sh3 


Invalided 


W 


Class  I. 
Parasites    and  parasitic    dis- 


Class  II. 
General     infectious     diseases 
(nonvenereal) 

Class  III. 
Constitutional  disorders  of  nu- 
trition      


Class  IV. 
Diseases  of  the  nervous  sys- 
tem   


Class  V. 
Diseasps  of  the  visual  appa- 
ratus   


Class  VI. 
Diseases  of  the  auditory  appa- 
ratus   


62 


Class  VII. 
Diseases  of  the  olfactory  ap- 
paratus   

Class  VIII. 
Diseases  of  the  nutritive  ap- 
paratus : 
Subsidiary  class  1 — 
Diseases  of  the  digestive 

apparatus 

Subsidiary  class  2 — 
Diseases  of  the  circula- 
tory apparatus 

Subsidiary  class  3 — 
Diseases  of  the  respira- 
tory apparatus 

Class  IX. 
Diseases  of  the  motory  appa- 
ratus   


Class  X. 
Diseases  of  the  cutaneous  ap- 
paratus   

Class  XI. 
Venereal  diseases  and  diseases 
of  the  genito-urinary  appa- 
ratus  

Class  XII. 
Cysts  and  new  growths 

Class  XIII. 
Injuries   

Class  XIV. 
Extraneous  bodies 

Class  XV. 
Poisons 

Class  XVI. 

Feigned  diseases 

Total  


2,769 


46 


1,039 


25J 


17 


871 


25 


1312 


2,66^ 

219 

1,0S9 

461 

1,348 

2,  .522 
43 

2,. 364 

12 

839 


33 


12 


127 


2,433 


26 


914 


184 


143 
40 
54 

56 


294 

3 

109 


15, 674 


2,466 
134 


159 


672 


16 


82 


287 
109 


913     196 


403 
1,297 

2,043 
31 

2,120 

12 

329 


1,373  '13,614 


102 


735 

15 

216 


^1 

3,0G1 


196 


9       2       5 


64 


2  I  21 


33 


25 


35 


80 


84 


m   407 


718 
21,345 

566 
7,288 
2,447 

939 

134 

12,453 
3,004 
7,009 

3,635 

11,823 

26,261 

389 

21,612 

47 

1,378 

20 


121.068 


292 


TEXT-BOOK  OF  HYGIENE. 

Chart  I. 


Causes  of  Death. 

Relation  dy  Scale. 

N9  of 
Deaths. 

Drowning. 

27 

Pneumonia 

15 

Typhoid  Fe\^cr. 

14 

Wounds. 

14 

Pu/monary  Tudercu/os/'s. 

13 

Star\/afion 

12 

Bri^hf-'s  Disease 

9 

Fracfure 

9 

ya/vuiarHesr/-  Disease. 

8 

A/coho/ism 

B^MM^^Ua 

9 

Cho/era . 

■M^^^KI 

6 

Poisons. 

m^^i^Bi 

6 

Br^onchifis,  C/7ronic. 

a^^BB 

4 

Dysentery,  Acute. 

m^^^ 

4 

I^emitten  t  Fe  ver. 

^^BM 

4 

Appendicitis- 

■H^ 

3 

Endocarditis. 

M9^ 

3 

Smallpox. 



3 

Burns. 

m^ 

2 

Cancer. 

^H 

2 

Cholera  Morbus 

r^ 

2 

Concu.ssion. 

^n 

2 

Contusion 

Bn 

2 

Miliary  Tuberculosis. 

^B 

2 

Diphtheria- 

2 

Yellow  Fever: 

2 

Haemorrhage  (Slomacti) 

1^^ 

S 

Intestinal  Obstruction. 

WK\ 

2 

Peritonitis- 

Bm 

2 

Abscess  of^  Liver. 

■BE 

2 

Abscess. 

ss 

Angina  Pectoris. 

^ 

Apoplexy. 

f^l 

Asthma. 

R 

In  testina  1  Catarrh- 

£3 

Dilation  of  Heart 

S 

Dengue  Fever. 

^ 

Diabetes. 

ra 

Dysentery,  Chronic- 

Heart  Failure,  5imp/e . 

s                                                                             / 

Intermittent  Fever - 

m 

Thermic  Fever. 

Castro  -  Enteritis. 

m 

Meningitis. 

Myocarditis- 

^ 

Oedema  ofLun^s 

H 

Middle  Ear  Disease- 

Paralysis- 

0 

Pleurisy- 

_ 

Py^mia 

B 

Septicaemia- 

ga 

Tuberculosis. 

B 

Ulcer  of  Stomach. 

a 

Rupture  of  Abdominal  Or^^ans 

Paralytic  Dementia. 

.B > 

J 

MORBIDITY  AND  MORTALITY  IN  SEAFARING  PEOPLE.       293 
Chart  II. 


IJJ 


Ij 


IJJ 


Ijj 


fl-l 


1-^ 


294 


TEXT-BOOK  OF  HYGIENE. 


The  number  of  persons  invalided  from  the  service  (including 
retirements  of  officers  for  disabilities  and  transfers  to  hospitals  for 
the  insane)  was  l.l-i-i,  or  about  3.8  per  cent,  of  mean  strength.  Two 
hundred  and  eleven  deaths  occurred  during  the  year,  or  0.41  per  cent, 
for  disease  and  0.26  per  cent,  for  injury.  Among  the  causes  for  ad- 
mission to  the  sick-list,  malarial  diseases  stand  first  with  1,408  admis- 
sions, wounds  ranking  next  with  942  admissions,  while  epidemic 
catarrh,  which  has  headed  the  list  for  the  last  three  years,  falls  to 
third  place,  with  877  admissions.  Dengue  fever  adds  531  admis- 
sions. Eheumatic  and  diarrheal  affections  rank  next  in  preva- 
lence, with  799  and  783  admissions  respectively.  The  number  of 
admissions  for  mumps  and  measles  was  almost  twice  as  great  as  in 
1901.  The  admissions  for  the  epidemic  diseases  are:  mumps,  330; 
measles,  245;  diphtheria,  65;  rubella,  48;  small-pox,  23.  Venereal 
diseases  were  as  follows:  Gonorrhea,  771;  sj'philis,  606;  chancroid. 
284;   alcoholism,  348. 

The  total  admissions  for  injuries  of  various  character  were 
2,940,  being  divided  among  wounds,  952;  contusions,  706;  sprains, 
612;  fractures,  242;  hernias,  175;  burns,  171;  luxations,  65; 
dro-RTiing,  27. 

Table  XXXVI  shows  at  a  glance  the  numerical  distribution  of  the 
eases  among  the  sixteen  classes  into  which,  for  convenience  sake  and 
statistical  reasons,  the  diseases  have  been  divided,  while  the  two  ad- 
joining charts  will  give  a  better  idea  (1)  of  the  more  prominent 
causes  of  death  and  (2)  the  prevalence  in  the  Navy  of  the  more  spe- 
cial diseases  and  injuries. 

An  example  showing  the  enormous  amount  of  work  in  marine 
sanitation  done  in  various  ports  of  the  world,  especially  in  the  port 
of  Hamburg  under  Dr.  Nocht,  of  the  detailed  records  that  are  kept 
and  of  the  excellent  and  valuable  statistical  tables  that  are  from 
time  to  time  given  to  the  medical  world,  the  following  will  bear 
ample  testimony:  During  the  last  seven  or  eight  years  there  were 
under  sanitary  control : — 


I.  In  Cuxhaven: 


Table  XXXVII. 


1896 

1897 

1898 

1899 

1900     1901 

1902 

78 
Disinfected  -were  . . 

116 
105 

148 
97 

229 
130 

579 
173 

665 
126 

846  ships. 
116  ships. 

MORBIDITY  AND  MORTALITY  IN   SEAFARING   PEOPLE.        295 
II.  In  Hamburg: 

Table  XXXVIII. 


1895 

1896 

1897 

1898 

1890 

1900 

1901 

1903 

19,359 

16,375 

15,458 

13,218 

14,099 

14,430 

17,708 

19,302  ships 

During  these  examinations  it  was  noted  that  the  following  num- 
bers of  cases  of  sickness  had  occurred  on  board  these  vessels  on  the 
trip  preceding  their  arrival  in  the  port  of  Hamburg,  namely: — 


Table  XXXIX. 


1895 

1896 

1897 

1898 

Internal  .... 
External .... 
Venereal . . : 

2,763  (143) 
2,038 

294 

431 

3,923  (144) 
1,867 
1,599 
357 

3,197  (122) 
2,355 

417 

425 

7,624  (105) 
2.379 
4,939 
306 

1899 

1900 

1901 

1902 

Internal  .... 
External .... 
Venereal .... 

9,805  (173) 
3,554 
5,932 
319 

10,789 

4,818 

5,631 

340 

14,365 

6,087 
7,221 
1,057 

15,163  cases 
5,513     " 
8,260     " 
1,390     " 

Brackets  (  )  mean  deaths. 

Their  distribution  among  the  most  important  diseases  was 
follows : — ■ 


as 


Table   XL. 


Cholera 

Yellow  fever 

Variola 

Diphtheria 

Malaria 

Typhoid 

Dysentery 

Consumption 

Scurvy 

Beri-beri 

Heat  and  heat-stroke. 
Heart  disease 


1895 


5  (4) 
40(24) 

6  (2) 


635  (5) 
7  (2) 

10 

25(10) 

37  (2) 
5  (3) 

83  (9) 


1896 


1 

48(26) 

3 

1 
961(12) 
10  (3) 
33  (5) 

9  (3) 
76(11) 
17  (5) 
54(10) 


1897 


2  (2) 
6  (5) 
1 

1 

807(20) 

3  (2i 
23  )1) 
20  (2- 
12  (1) 
2')  (7) 
27  (7) 


1898 


2  (2) 


1 

584  (3) 
7  (1) 
12  (1) 

11  (3  J 
1 

12  (4) 
69(15) 
15  (3) 


1 

3 
1 

547(27) 

5 
13  (2) 

8  (5) 

5 

39(19) 
27  (2) 
23  (8) 


1900 


10  (8) 

1 

1 
404(21) 

6  (1) 
10  (1) 
13  (8) 
12 

U  (8) 
86(19) 
23  (7) 


1901 


2 

1 

4 
591(14) 
33  (1) 
25  (2) 
20  (6) 
35  1 4) 
14  (8) 
63  (3) 
28  (5) 


1902 


14  (7) 
5  (4) 
3 

4  O) 
593(2^) 

17  (6) 

22 

11  (2) 

22 

45  (3) 


296 


TEXT-BOOK  OF  HYGIENE. 


During  the  last  three  years  the  number  of  cases  of  sickness  occur- 
ring among  passengers  on  138  steamers  that  came  into  tlie  port  of 
Hamburg  was  3450.  Two  hundred  and  thirty-nine  of  these  ended 
fatally  and  1380  were  infectious  diseases:  measles,  scarlatina,  rube- 
ola, diphtheria,  variola,  etc. 

On  one  ship  two  cases  of  plague  occurred.  Eelatively  numerous 
are  said  to  be  abortions  and  uterine  haemorrhages,  caused  by  sea- 
sickness. On  board  these  same  steamers  4802  seamen  received  medical 
treatment;  among  these  389  cases  were  infectious  diseases,  with  25 
deaths.  The  annual  average  number  of  sick  seamen,  derived  from  the 
records  of  the  last  eight  years,  as  arriving  in  the  port  of  Hamburg, 
is  2343,  being  distributed,  likewise  by  annual  averages,  as  follows: 
Internal  diseases,  1047 ;  external  diseases,  795 ;  venereal  diseases, 
553.  According  to  the  calculations  of  Dr.  Nocht,  every  physician 
employed  on  these  steamers,  during  a  forty-days'  trip,  had  under 
treatment,  on  the  average,  ten  serious  cases  of  sickness. 

Casualties  and  Disabilities  Due  to  Shipwreck. — The  total  loss  in 
vessels  caused  by  shipwreck,  during  a  period  of  ten  years,  amounted 
on  an  average,  (1)  in  the  English  merchant  marine,  to  2.43  per  cent.; 
(2)  in  the  French  merchant  marine,  to  2.36  per  cent.;  and  (3)  in  the 
German  merchant  marine,  to  1.86  per  cent.  In  the  German  service 
the  total  loss  of  human  life  due  to  these  accidents  was  0.53  per  cent, 
of  the  crews.  The  Seaman's  Insurance  Bureau  at  Hamburg,  in  its 
annual  report  for  1893,  gives  the  following  valuable  information  with 
regard  to  these  casualties: — 

Table  XLI. 

Accidents  Reported. 


Vessels 

Number  of  Men 

Number  of 
Accidents 

Accidents 
per  1000 

Deaths  per  lOOO 

Steamers  

24,636 

15,595 

1,277 

1,423 

636 

5 

57.76 

40.79 

3.93 

6.09 

Sailing  vessels   

Employed  

21.74 

The  Seaman's  Insurance  Bureau,  in  1892,  had  on  its  books 
43,023  insured  seamen  and  paid  insurance  to  1668  persons.  Out  of 
this  number  the  disability  incurred  by  1571  persons  proved  to  be 
but  temporary  and  lasted  less  than  13  weeks;  of  the  remaining  97, 
8  remained  permanently  disabled  and  the  rest  died.  The  total  num- 
ber of  registered  sea-going  vessels  at  the  time  was  2742  sailing  ships, 
manned  by  17,522  men,  and  986  steamers,  manned  by  24,113  men. 


THE  DRAINAGE  OF  SHIPS. 

Table  XLII. 

Accidents  Occurred  as  follows  : 


297 


Year 

Number  of 
Ships 

Number  of 
Men 

Died 

Number  of 
Passengers 

Died 

1889 
1890 
1891 

116 

92 

116 

1,015 
937 

1205 

208 
169 

177 

331 
174 
160 

274 

7 

30 

THE  DRAINAGE  OF  SHIPS. 

We  say  of  a  city  or  town  that  it  is  drained  either  according  to  the 
combined  or  the  separate  system,  in  accordance  as  to  whether  all  the 
offal  is  discharged  combinedly  through  one  set  of  pipes,  or  whether 
the  rain  and  the  washwater  are  made  to  flow  through  a  pipe  system 
separate  from  this.  In  keeping  with  this  nomenclature  we  may  say 
of  a  ship  that  it  is  drained  in  accordance  with  the  principles  of  the 
separate  system.  For,  although  the  methods  of  ships'  drainage  are 
perhaps  more  complicated  than  are  those  of  cities  and  towns,  they, 
naturally,  may  be  divided  into  two  principal  methods : — 

1.  The  sea-water  coming  on  board,  the  rain-water,  the  wash- 
water,  the  water  circulating  in  the  pipes  of  the  flushing  system,  after 
passing  through  the  various  closets,  the  refuse  from  the  kitchen,  the 
ashes  from  the  furnaces,  are  all  made  to  pass  overboard  in  the  most 
direct  ways. 

2.  The  refuse  matters  from  the  engine-  and  boiler-  rooms,  those 
from  the  various  magazines  and  storerooms,  the  rain-,  sea-,  and  wash- 
water  from  the  lower  decks,  all  these  find  their  way  into  the  lowest  and 
most  dependent  compartments  of  the  ship  by  gravity,  finally  collect- 
iBg  in  what  is  known  as  the  bilge-room.  Thence  the  combined  mix- 
ture, known  as  bilge-water,  is  pumped  overboard  by  powerful  station- 
ary suction-pumps.  These  suction-pumps  generally  terminate,  with 
their  open  mouths  looking  downward,  within  a  few  inches  from  the 
bottom  of  the  ship,  being  protected  by  wire  gauze  baskets  to  keep  out 
solid  matters.  Their  arrangement,  while  simple  enough  in  a  wooden 
ship,  or  even  an  iron  merchant-ship,  in  a  fully  equipped  modern 
battleship,  the  number  of  pipes  of  all  sizes,  their  many  valves  and 
cross  connections,  are  positively  bewildering,  and  none  but  an  expert 
can  be  entrusted  with  the  laying  out  of  a  complete  system  in  perfect 
and  absolutely  reliable  working  order.  The  drains  are  usually  di- 
vided into  main,  auxiliary,  and  spcondary  drains,  according  to  size. 
The  large  fifteon-infh  main  drain  on  a  big  battleship  is  only  used  to 


298  TEXT-BOOK  OF  HYGIENE. 

pump  out  very  large  quantities  of  water  in  case  the  ship's  bottom 
is  punctured;  while  the  auxiliary  drains  are  employed  in  pumping 
out  the  accumulated  bilge-water  at  regular  intervals,  and  the  second- 
ary drains  connect  with  the  smaller  local  accumulations. 

The  pumping  and  drainage  system  below  the  protective  or  water- 
tight deck  of  a  modem  man-of-war  may  be  said  to  be  divided  into 
three  parts,  viz :  emergency,  surface,  and  double-bottom  drainage. 
Each  part  is  provided  with  separate  and  distinct  piping,  working 
independently,  if  desired,  yet  so  interconnected  with  the  others  by 
means  of  valves  that  they  all  may  be  made  to  work  in  unison. 

The  main  drain  (see  Fig.  33)  may  be  styled  the  emergency 
part,  and  consists  of  a  pipe,  ranging  in  size  from  by^  inches  to  15% 
inches,  according  to  the  size  and  type  of  the  ship,  and  extending  from 
the  after  part  of  the  forward  fire-room  to  the  after  part  of  the  after 
engine-room;  its  flanges  are  made  water-tight  on  every  main  water- 
tight bulkhead  it  is  made  to  pierce.  The  main  drain  generally  runs 
on  one,  usually  that  side  of  the  vessel  where  the  center  line  longitu- 
dinal watertight  bulkhead   is  fitted,   throughout  the  length  of  the 

boiler  compartments,  branching  ' j '  shape  just  aft  of  the  for- 
ward bulkhead  of  the  engine  space,  a  branch  being  carried  into  each 
engine-room  and  connected  to  the  main  centrifugal  pump  in  each  of 
these  compartments.  In  each  compartment  traversed  by  the  main 
drain  is  a  suction  valve,  the  full  diameter  of  the  pipe,  operated  at 
the  valve  and  also  by  means  of  a  rod  from  the  deck  above.  Branches 
from  this  main  drain  are  led  through  the  center-line  bulkhead  and 
fitted  with  valves  at  the  end,  so  that  all  of  the  main  machinery  com- 
partments are  connected  directly  to  this  large  emergency  drainage 
pipe. 

Each  steam-pump  throughout  the  machinery  space,  which  in  any 
manner  is  connected  with  drainage,  has  a  suction  connection  with  the 
main  drain,  so  that  one  pump  or  all  pumps  may  be  made  to  work  on 
this  pipe  whenever  required  to  do  so.  The  main  drain  is  used  only 
in  case  of  an  emergency,  that  is,  when  the  water  in  any  compartment 
is  found  to  be  rising  above  the  floor-plates  and  cannot  be  controlled 
by  the  other  drainage  connections.  Such  an  emergency  would  arise 
only  on  account  of  a  vessel  striking  rocks  or  taking  ground,  thus 
injuring  the  inner  bottom  and  causing  a  leak  of  great  magnitude,  or 
by  a  torpedo  striking  below  the  water  line  and  injuring  one  or  more 
watertight  subdivisions. 


■  OUTSIDE    PLATING 


.DOCKING     KetLS 


Fig.    33. — Cross-section    of    Ship,    Showing    Arrangement    of 
Drainage  System. 


(299) 


300  TEXT-BOOK  OF  HYGIENE. 

By  surface  drainage  is  meant  the  drainage  of  all  water  that  col- 
lects on  top  of  the  inner  bottom  in  engine-  and  boiler-  rooms,  in  store- 
rooms or  other  places  throughout  the  whole  length  of  the  ship,  not  in 
double  bottoms.  Each  watertight  compartment  throughout  the  length 
of  the  inner  bottom  has  provided  at  its  lowest  part  what  is  known 
as  a  bilge-well  (see  Fig.  33),  that  is,  a  rectangular,  cup-shaped  de- 
pression about  10  X  18  X  6  inches,  worked  into  the  inner  bottom  plat- 
ing. Into  these  bilge-wells  the  suction  ends  of  all  the  suction  pipes 
are  placed,  so  as  to  provide  the  conditions  for  each  compartment  be- 
ing pumped  as  dry  as  possible.  The  principal  pipe  attending  to  sur- 
face drainage  is  called  the  "secondary  drain"  (see  Fig.  33),  to  dis- 
tinguish it  from  the  pipe  called  the  "main  drain."  The  secondary 
drain  usually  runs  on  the  side  of  the  ship  opposite  to  the  main  drain, 
and  extends  from  the  forward  end  of  the  forward  boiler-room  to  the 
after  end  of  the  after  engine-room,  connecting  to  a  manifold  (in  other 
words,  a  series  of  valves  cast  in  one  chest)  at  each  end  and  having 
branches  leading  to  each  bilge-well  in  every  watertight  compartment 
throughout  the  machinery  space. 

Each  steam-pump  connected  with  the  drainage  system,  except 
the  main  centrifugal  circulating  pumps,  is  provided  with  a  suction 
to  the  secondary,  and  is  so  arranged  that,  by  the  manipulation  of 
certain  valves,  any  compartment  may  be  pumped  by  any  pump  or  by 
all  pumps,  if  necessary.  From  the  manifold,  at  each  end  of  the 
machinery  space,  branch  pipes  extend  to  the  several  compartments 
forward  and  aft,  so  that  the  pumping  of  the  several  compartments 
forward  and  aft  may  be  controlled  from  within  the  machinery  space. 
The  suction  ends  of  all  the  branches  within  the  machinery  space  are 
provided  with  Macomb  strainers,  and  the  suction  ends  outside  of  the 
machinery  space  are  protected  by  perforated  box-strainers,  thus  pro- 
tecting the  piping  as  well  as  the  pumps  from  becoming  clogged  by 
any  extraneous  matter. 

In  addition  to  the  secondary  drain,  the  extensive  functions  of 
which  may  noAv  be  realized  from  the  above  description,  a  separate 
pipe,  known  as  the  independent  '^Dilge  suction"  (see  Fig.  33)  is  led 
from  each  steam-pump  to  the  bilge-well  of  its  own  compartment,  so 
that  each  compartment  may,  by  its  own  pump,  be  kept  dry  without 
dirtying  up  the  secondary  drain.  For  pumping  the  crank-pit  a 
small  pump  on  the  main  shaft  of  the  engine,  known  as  the  "shaft 
bilge-pump,"  is  provided.  This  crank-pit,  however,  is  also  connected 
to  the  secondary  drain  and  an  independent  suction,  so  that,  in  case  the 


THE  DRAINAGE  OF  SHIPS.  301 

shaft  bilge-pump  is  out  of  order,  the  water  in  the  crank-pit  may  still 
be  taken  care  of. 

The  double  bottom  is  either  flooded  or  pumped  through  a  pipe 
known  as  the  "double-bottom  pumping  or  flooding  main"  (see  Fig. 
33),  which  is  a  single  pipe  in  boiler  space  and  a  single  pipe  in  engine 
space,  with  a  branch  controlled  by  a  valve  leading  into  each  water- 
tight compartment  of  the  double  bottom  and  with  a  connection  direct 
to  the  sea  and  to  one  or  two  steam-pumps  within  the  machinery  space. 
The  double  bottoms  throughout  the  machinery  space  are  the  only 
places  provided  with  a  flooding  connection;  while  the  double  bot- 
toms forward  and  aft  the  machinery  space  have  suction  connections 
only,  and  are  pumped  by  means  of  the  secondary  drain  through  the 
manifold  in  the  forward  boiler-room  and  the  after  engine-room. 

Summary. — From  the  foregoing  brief  description  it  will  be  seen 
that  the  main  drain  is  an  emergency  drain,  being  used  only  to  reduce 
large  volumes  of  water;  it  is  never  brought  into  requisition  for  the 
purpose  of  reducing  surface  water.  That  the  secondary  drain,  with 
its  ramifications  and  auxiliaries,  is  employed  to  reduce  all  surface 
water  usually  collecting  in  the  machinery  space  or  such  water  as  col- 
lects in  holds  or  store-rooms,  or  for  pumping  out  the  forward  or 
after  tanks;  finally,  that  the  double  bottom  and  flooding  main  looks 
after  all  water  within  the  double  bottoms. 

Ko  suction  pipes  are  led  into  the  coal  bunkers  or  magazines. 
Such  water  as  collects  under  the  floor-ceilings  of  the  coal-bunkers 
is  pumped  out  by  means  of  a  hose  passed  through  the  coal-bunker 
door.  The  magazines  proper,  without  handling  rooms,  are  pumped 
out  after  a  flooding  by  means  of  a  hose  passed  through  a  cap  in  the  top 
of  the  magazine. 

In  most  of  the  wooden  ships  the  bilge-room  consists  of  a  tri- 
angular-shaped space  running  along  the  entire  length  of  the  ship's 
bottom  and  inclosed  between  the  bottom,  the  loose  deck-planking,  and 
the  keelson  (see  Fig.  34).  The  numerous  ribs  of  the  ship  divide  this 
space  transversely  into  a  number  of  partitions,  between  which,  how- 
ever, communications  are  established  through  borings,  forming  the 
so-called  waterways  (see  Fig.  35).  In  iron  ships,  the  ribs  being  fur- 
ther apart,  these  partitions  are  broader  and  more  spacious,  as  well  as 
deeper  (Fig.  35). 

When  double  bottoms  were  introduced,  and  when  these  were 
used  for  the  storage  of  iron  tanks  containing  feed-water  for  the 
boilers,  the  bilge-spaces  underwent  a  lateral  displacement  and  came 
to  be  located  between  the  inclinod  planes  of  the  ship's  sides  and  tliose 


fco 

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(303) 


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*•   iONGITUOINALS 

rig.  37.— STiowing  Location  of  Bilge-spate  on  Top  of  Double  Bottom. 


20 


(305) 


306  TEXT-BOOK  OF  HYGIENE. 

of  the  double  bottoms,  where  the}^  took  the  form  of  a  shallow  gutter 
(see  Fig.  36).  When,  still  later,  the  double  bottoms  were  run  up 
still  higher  on  the  ship's  sides,  these  gutters  disappeared  and  the 
bilge-spaces  again  were  made  to  occupy  the  center  line  on  top  of  the 
double  bottoms  (see  Fig.  37).  A  further  transverse  division  of  the 
bilge-room  occurred  through  the  introduction  of  complete  watertight 
bulkheads,  running  from  side  to  side  and  from  the  bottom  up  to  and 
through  several  decks,  dividing  these  into  complete  and  separate  com- 
partments in  a  transverse  direction  and  without  any  communication 
between  them,  except,  perhaps,  through  watertight  doors. 

Thus  we  see  how  the  changes  that  have  taken  place  from  time  to 
time  in  the  methods  of  ships'  construction  have  also  materially  af- 
fected the  location  of  the  bilge-spaces,  and  thus  radically  altered  the 
composition  and,  consequently,  the  sanitary  significance  of  the  bilge 
itself.  The  old  conception  of  bilge-water  no  longer  holds  good  and 
needs  a  change. 

One  of  the  principal  sources  of  the  bilge-water  in  wooden  ships 
was  the  sea-water,  which  in  all  wooden  ships  leaked  through  the  bot- 
toms. This  water  would  accumulate  in  the  most  dependent  portion 
of  the  ships'  bottoms,  where  it  would  take  up  the  offal  from  all  sorts 
of  cargo  and  provisions,  the  wash-water  from  the  lower  decks,  the 
cadavers  of  small  animals,  dirt  and  dust  from  the  sweepings,  etc., 
etc.  The  whole  would,  in  time,  result  in  a  thick,  black,  malodorous, 
fermenting  fluid,  filling  the  air  with  foul-smelling  gases,  splashing 
through  the  loose  flooring  laid  over  it,  while  the  ship  was  under  way, 
and  soiling  it  and  everything  else  in  contact  with  it. 

On  iron  ships,  the  sea-water  as  the  chief  source  of  the  bilge- 
water  leaking  through  the  ship's  bottom  is  almost  entirely  done  away 
with,  for  their  bottoms  allow  no  salt  water  to  get  through  them. 
The  only  place  through  which  salt  water  can  still  get  into  the  bilge- 
room  is  the  shaft-alley.  The  consequence  is  that,  with  ordinary  care, 
it  is  possible  to  keep  the  bilge-room  in  these  ships  dry.  Often  the 
spaces  between  the  timbers  are  filled  with  cement  right  up  to  the 
limber  ho'.es  (see  Fig.  36),  so  as  to  guide  the  bilge-flow  from  one 
partition  into  the  other  and  to  prevent  any  accumulation  in  any  of 
them. 

Thus,  then,  we  will  have  to  admit  that  what  was  known  as  the 
bilge  on  board  the  old  wooden  ships  can  no  longer  be  considered  the 
same  thing  on  board  our  more  modern  iron  ships.  But  still,  differ- 
ent though  it  be  in  composition,  the  bilge  will  and  must  continue  to 
receive  the  most  careful  attention  and  scrutiny  of  the  ship's  sani- 


THE  COMPOSITION  OF  THE  BILGE. 


307 


tarian,  as  remaining  a  source  of  contamination  of  the  ship's  atmos- 
phere, whenever  it  is  allowed  to  accumulate  and  to  undergo  decom- 
position inside  of  the  ship.  Both  chemical  and  bacteriological  ex- 
aminations of  the  bilge  will  always  have  to  be  done,  whenever  the 
health  of  the  personnel  of  a  ship  becomes  a  matter  of  serious  concern. 


THE  COMPOSITION  OF  THE  BILGE. 

Notwithstanding  the  fact  that  bilge-water  had  always  been  looked 
upon  by  all  classes  of  seafaring  people  as  the  most  dreadful  disease- 
breeder  and  as  the  most  universal  source  of  atmospheric  contamina- 
tion on  board  all  classes  of  ships,  no  serious  scientific  attempt  at 
analysis  was  made  until  1885  (Belli),  when  Nicati  and  Eietsch  pub- 
lished the  results  of  their  investigations  on  the  viability  of  the  cholera 
bacillus  in  bilge-water.  The  possibility  of  importing  this  bacillus  into 
Europe  in  bilge-water  had  been  thought  of,  but  the  results  of  the 
experiments  proved  negative.  A  year  later,  Koch  and  Gaffky  made 
some  experiments  on  the  disinfection  of  bilges  and  came  to  the  con- 
clusions that  mercuric  bichloride  was  the  most  efficient  means  for 
the  disinfection  of  bilges  and  bilge-water.  In  1891  Forster  and 
Eingeling  published  the  most  thorough  and  painstaking  experiments 
that  had  been  made  on  the  subject  up  to  that  time.  The  most  im- 
portant fact  brought  out  by  their  experiments  and  observations  was 
that  the  composition  of  bilge-water  varied  within  the  widest  limits, 
not  only  in  different  ships,  but  also  in  different  parts  of  the  same 
ship,  as  is  best  shown  in  one  of  their  own  tables: — 


Table  XLIII. 

Variatioms  in  Composition  of  Bilgewater. 


Dry  Residue 

Combustible 
Substances 

Oxygen  Con- 
sumed 

Chlorine 

Sulphuric   Acid 

Ammonia 

58-244.8 

0.1-165.2 

0.06-11.4 

1.6-86.3 

0.11-2.65 

0.002-0.91 

Interesting  in  this  connection  are  the  observations  of  Dr.  ISTocht, 
which  were  published  in  1893  and  which  are  shown  in  the  next 
table : — 


308 


TEXT-BOOK  OF  HYGIENE. 
Table  XLIV 

Showing  Composition  of  Bilge. 


Ship 

Where  Formed 

General  Properties 

Sail  (wood) 

((       (( 

"  (iron) 

Steamer  (iron) 
i(             (( 

Cargo-room 

t(       (( 

Machine-room 

Cargo-room 

Machine-room 

Brown,  turbid,  muddy 
Black,  turbid,  very  muddy 
Yellowish,  clear,  thick 
Clear,  colorless 
Turbid,  black,  very  muddy 
Opaque,  colorless,  no  sediment 

Odor 

Beaction 

Chlorine  per  Litre 

Number  of  Germs  per 
Cubic  Centimeter 

Sweetish 

Neutral 

9,585 

325,000 

Stinking 

Slightly  Alkaline 

12,780 

100,000 

No  odor 

Strongly  Alkaline 

49,500 

300 

No  odor 

Neutral 

664 

15,000,000 

Foul 

Slightly  Alkaline 

10,615 

3,000,000 

No  odor 

Neutral 

5,573 

4,600 

Two  years  later  Eingeling  discovered  two  pathogenic  anaerobes 
(septic  vibrio  and  tetanus)  in  a  portion  of  water  taken  from  near  the 
keel  of  a  ship,  and  in  1896  Eocci,  then  surgeon  in  the  Royal  Italian 
Navy,  studied  the  disinfectant  value  of  milk  of  lime  upon  the  most 
common  bacteria  found  and  isolated  from  bilge-water.  The  very  latest 
and,  at  the  same  time,  the  most  thorough  and  extensive  examinations 
into  the  composition  of  bilge-water  ever  made  are  those  published  by 
Dr.  Carlos  M.  Belli,  of  the  Royal  Italian  Navy.  These  results  are  so 
important,  especially  as  representing  the  facts  as  they  exist  on  board 
men-of-war,  that  his  tables  have  been  in  part  reproduced. 

An  examination  of  these  tables  shows  that  Belli  employed  the 
most  up-to-date  chemical,  microscopical,  and  bacteriological  methods 
in  his  work  on  bilge-water.  Of  quite  particular  interest  are  his  inocu- 
lation experiments.  He  inoculated  animals  subcutaneously  with 
samples  of  bilge-water  amounting  to  ^/^  cubic  centimeter  for  a  dose, 
in  order  to  ascertain  whether  they  produced  any  possible  pathogenic 
effect.  In  none  of  his  many  experiments  was  such  an  effect  noted, 
although  his  animals  were  kept  under  observation  for  two  months 
after  being  inoculated.  He,  moreover,  tested  the  cultural  properties 
of  various  types  of  bilge-water  in  both  the  natural  state  as  well  as 
after  filtering  it  through  Berkefield  filters.  As  test-objects,  34-hour 
cultures  of  typhoid,  cholera,  icteroides,  and  staphylococcus  pyog.  aur, 
were  used.  Although  the  numerous  and  important  details  of  this  most 
extensive  investigation  on   the   composition   of  bilge-water  must  be 


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310  TEXT-BOOK  OF  HYGIENE. 

Table  XLVI. 

Bacteriological  Examination  of  Bilge-waler.     ( Belli. ) 


Bilge-type 

Ships 

Average 

Number  of 

Bacteria 

per  c.cm. 

Species  Identified 

Engine- 
room 

Monznmbano 

Calabria 

Dogali 

C.  Alberto 

239,000 

2,141,000 

984,000 

307,000 

Many  colonies  of  chromogenic  saprophytes  ; 

some  colonies  resembling  bacillus  coli. 
Few  hyphomycetes,  and  of  the  schizomycetes 
those  common  in  sea  water. 
Very  few  schizomycetes  ;   chromogenic  cocci 

and  few  bacilli,  of  which  fiuor  liquefaciens 

are  in  greatest  number  ;  few  proteal. 
Numerous  colonies  of  hyphomycetes  ;  of  the 

schizomycetes,  some  colonies  of  cladothrix  ; 

large  numbers  of  chromogenic  water  coco 

and  bacilli. 

Boiler- 
room 

Mon/ambano 
Calabria 
Dogali 
C.  Alberto 

362,000 
1,016,000 
3,289,000 
1,000,000 

Sparse  number  of  fungi,  many  fluor  liquefa- 
ciens. 

Mostly  hyphomycetes  and  blastomycetes ; 
few  species. 

Very  large  number  of  schizomycetes,  common 
to  engine-rooms. 

Sparse  hyphomycetes;  schizomycetes,  common 
to  engine-rooms. 

Provision- 
room 

Monzambano 

Calabria 

Dogali 

652,000 

333,000 

1,261,000 

Various  colonies  of  proteal  and  pota'o-bacilli. 
Principally  blastomycetes,  less  hyphomycetes. 
Mostly  all  blastomycetes;  few  hyphomycetes, 
some  colonies  of  sarcina  lutea. 

Table  XLVII. 

3Iicroscopical  Examination  of  Bilge-water.     {Belli.) 


Type  of  Bilge 

Ships 

Results 

Machine-room 

Monzambano 
Calabria 

Dogali 
C.  Alberto 

Crystals  of  organic  and  inorganic  salt,  protozoa. 
Pretty  large  numbers  of  algae  and  protozoa,  crys- 
tals, hemp- threads. 
Salt  crystals,  no  living  forms. 
Salt  crystals,  hemp-threads,  no  protistse. 

Boiler-room 

Monzambano 

Calabria 

Dogali 

C.  Alberto 

Coal-dust. 

Coal-dust,  no  living  forms. 

Coal-dust,  few  protozoa  (ameboid  and  rhizopod 

forms. ) 
No  living  forms,  sparse  carbon  particles  and  salt 

crystals. 

Provision-room 

Monzambano 

Calabria 

Dogali 

Mineral  and  vegetable  dust,  numerous  rhizo- 
pods  and  flagellates. 

Salt  crystals,  vegetable  fibres  and  grains,  few 
protozoa. 

Vegetable  fibres  and  hairs,  ?alt  crystals,  no  pro- 
tozoa. 

THE  COMPOSITION  OF  THE  BILGE.  311 

studied  in  the  original  monograph  in  order  to  be  properly  appreciated, 
it  would  seem  unavoidable  to  give  a  brief  summary  of  the  results 
in  this  place. 

1.  Bilge- water  of  the  Engine-room  Type. — To  judge  from  the 
amount  of  chlorine  which  this  water  contained,  it  was  concluded  that 
the  basis  of  it  was  salt-water  mixed  with  a  certain  amount  of  sweet 
water  derived  either  from  rain-water  or  condensed  water,  added  to 
which  a  variable  amount  of  machine-oil  was  found.  The  relative 
proportions  in  the  amounts  of  ammonia,  nitrous  acid,  nitric  acid, 
organic  matters  present;  the  absence,  on  the  other  hand,  of  sulphur- 
etted hydrogen,  naturally  led  to  the  conclusion  that  the  processes  of 
decay  in  this  type  of  water  are  extremely  slight.  This  is,  moreover, 
confirmed  by  the  absence  of  bacteria,  always  present  in  decaying  sub- 
stances.    These  waters  possess  no  pathogenic  properties. 

2.  Bilge-water  of  the  Boiler-room  Type. — The  chemical  analysis 
of  the  waters  belonging  to  this  type  shows  that,  in  ships  lying  at  an- 
chor, these  waters  are  preponderatingly  made  up  of  sweet  water, 
formed  in  all  probability  from  the  feed-water  of  the  boilers  and  part 
of  which  is  spilled  in  the  process  of  filling.  In  ships  under  way  it 
changes  its  character  from  a  sweet  to  a  salt  water.  Here,  also,  pro- 
cesses of  decay  were  absent. 

3.  Bilge-water  of  the  "Cambuse"  Type. — The  chemical,  micro- 
scopical, and  bacteriological  gharacters  of  this  type  were  found  to 
vary  quite  considerably.  The  sedimentary  portion,  under  the  micro- 
scope, showed  small  grains,  fibers,  hairs  from  planks,  many  forms  of 
crystals,  algae,  and  protozoa.  The  most  common  type  resembled  sea- 
water  mixed  with  various  contents  from  barrels.  Acetic  fermenta- 
tion was  frequently  present,  while  other  processes  of  decay  were 
absent. 

4.  Bilge-water  of  the  Store-room  Type. — This  type  of  water  is 
essentially  a  sweet  water  with  which  a  small  amount  of  salt  water  is 
mixed.  It  is  probably  for  the  most  part  rain-water.  Processes  of 
decay  are  here  present  constantly. 

It  will  be  seen  that,  from  the  physical,  chemical,  and  micro- 
scopical characters  of  these  four  different  types  of  bilge-water,  it  is 
easy  to  distinguish  one  from  the  other;  but  even  without  taking 
these  into  account,  it  is  still  possible  to  distinguish  the  engine-room 
bilge  by  the  oil  with  which  it  is  mixed ;  that  from  the  boiler-room  by 
the  coal-dust  or  soot  which  it  contains ;  that  from  the  cambuse  by  the 
acetic  acid;  and  that  from  tbe  store-rooms  by  the  foul  odor  of  the 
decaying  substances  which  it  contains. 


312  TEXT-BOOK  OF  HYGIENE. 

From  a  hygienic  point  of  view  it  is  worthy  of  being  emphasized 
that  the  different  bilge-waters  in  battleships,  especially  those  from 
the  engine-  and  boiler-  rooms,  show  either  no  evidence  at  all  of  decay 
going  on  in  them,  or  that  the  evidence  is  present  only  to  a  very  slight 
degree.  This  condition  can  only  be  the  result  of  the  better  sanitary 
attention  which  these  places  receive  on  men-of-war,  when  contrasted 
with  similar  places  on  merchant  ships.  In  the  bilge-waters  coming 
from  beneath  store-rooms,  chemical  examination,  even  here,  shows 
evidence  of  advanced  processes  of  decay  in  spite  of  the  fact  that  the 
stores  in  question  could  not  naturally  be  considered  as  very  decay- 
able.  One  of  the  most  interesting  facts  brought  to  light  by  the  bac- 
teriological examination  is  this :  that  the  engine-  and  boiler-  room 
bilges  of  battleships  contain  either  no  proteae  at  all  or  their  numbers 
are  very  small,  while  the  store-room  bilges  literally  teem  with  them. 

The  persistently  negative  result  obtained  from  the  inoculation 
of  bilge-water  into  experimental  animals  would  indicate  that,  at  least 
under  ordinary  conditions,  these  waters  are  free  from  both  pathogenic 
germs  and  poisons.  This,  of  course,  does  not  exclude  the  possibility 
that,  under  other  conditions,  they  might  become  the  carriers  of 
pathogenic  germs,  although,  as  has  been  shown,  this  danger  even  then 
would  not  be  of  long  duration,  since  experiments  have  shown  that 
the  vitality  of  pathogenic  germs  in  these  waters  rarely  endures  beyond 
five  days.  It  was  also  found  that  the  dirtier  such  water  was,  the  less 
the  chances  of  the  survival  of  disease-producing  germs  would  be. 

Altogether,  then,  it  would  seem,  from  an  analysis  of  the  total 
results  of  these  investigations,  as  if  the  dangers  to  the  ships'  per- 
sonnel from  the  bilge-waters  on  board  battleships  had  been  slightly 
exaggerated,  or  could  not,  at  any  rate,  be  at  all  compared  to  what 
they  are  on  ships  of  the  mercantile  marine.  Such  a  result,  it  must, 
however,  be  remembered,  can  only  l>e  due  to  the  strict  sanitary  super- 
vision accorded  the  bilges  on  men-of-war  generally.  Frequent  cleans- 
ing of  the  bilges,  aided  by  regular  timely  disinfection,  must,  in  the 
end,  be  depended  upon  for  rendering  all  kinds  of  bilges  absolutely  free 
from  danger  to  the  health  of  the  men. 

THE  SHIP. 

1.  Construction. — Desirable  as  it  would  seem,  by  way  of  an  intro- 
duction into  marine  sanitation,  to  give  a  brief  outline  of  ships'  con- 
struction, space  does  not  permit  here  to  give  more  than  the  gross 
divisions  of  a  typical  vessel.    Fortunately,  the  points  regarding  marine 


THE  SHIP.  313 

architecture  that  it  is  absolutely  necessary  for  the  sanitarian  to  know 
are  few,  and  need  hardly  extend  beyond  a  knowledge  of  the  materials 
of  which  a  ship  is  built,  its  various  divisions  and  compartments  and 
the  special  uses  to  which  these  are  put,  in  order  to  enable  him  to  suc- 
cessfully trace  the  sources  of  mischief  to  human  life  produced  thereby. 
The  marine  sanitarian  need  not  be  a  constructor,  any  more  than  the 
public  health  officer  need  be  an  architect  or  an  engineer. 

For  the  marine  architect  by  profession,  the  problem  of  construct- 
ing a  small  gunboat  varies  immensely  from  that  of  a  large  battle- 
ship, while  for  the  marine  sanitarian  most  of  the  problems  that  come 
within  his  province  remain,  fundamentally  at  least,  the  same  in  both 
cases.  Thus,  every  ship  of  no  matter  what  type  or  description  is  more 
or  less  damp,  dark  between  decks,  and  difficult  to  ventilate  thoroughly, 
so  that  it  may  safely  be  taken  for  granted  that  dampness,  darkness, 
and  poor  air  are  the  three  main  and  most  constant  factors  entering 
into  every  problem  of  ships'  sanitation.  When  we  add  to  these  ex- 
treme heat  for  all  large  steam  vessels  of  modern  construction,  we  have 
indeed  all  the  four  elements  against  the  influences  of  which  sani- 
tarians must  direct  their  principal  efforts. 

The  difference  between  merchant  ships  and  warships  grows  wider 
every  year.  Thus,  for  instance,  in  a  modern  Lloyd  steamer  there  are 
at  present  five  decks.  Beginning  from  above  downward  we  have,  first, 
the  sun-deck;  next,  the  promenade  deck;  third,  the  upper  deck; 
fourth,  the  main  deck;  and  fifth,  the  'tween-deck.  Below  the  last 
deck  and  abaft  the  engine-room  there  is  the  shaft-alley,  and  in  the 
corresponding  situation  forward  of  the  boiler-room  we  have  the  coal- 
bunk'ers  and  the  various  store-rooms  for  provisions.  On  the  berth- 
deck,  from  bow  to  stern,  there  are  the  bunks  for  the  steerage  passen- 
gers, and  also  on  the  main  deck  forward  of  the  smoke-pipe.  The 
crew  lives  on  the  forward  part  of  the  upper  deck,  under  the  fore- 
castle. The  first  cabins  and  the  rooms  for  the  officers  are  on  the 
promenade  and  upper  decks. 

The  cubic  space  to  be  allowed  per  man  is  nowadays  prescribed  by 
law  in  every  civilized  country,  and  usually  amounts  to  100  cubic  feet, 
with  a  minimum  floor  area  of  9  feet.  This  is  said,  especially  by 
English  surgeons,  to  be  too  small  an  amount,  but,  while  admitting  the 
justice  of  the  complaint,  as  Kulenkampf  and  N'ocht  have  pointed  out, 
part  of  the  unhealthfulness  of  the  quarters  lies  on  the  side  of  the 
interior  arrangements  of  their  living  spaces,  as  well  as  in  the  insuffi- 
ciency of  the  available  aic-space.  ISTocht,  in  1895,  measuring  100 
ships,  found  the  amount  of  air-space  allowed  per  man  to  be   125 


314  TEXT-BOOK  OF  HYGIENE. 

cubic  feet,  that  is,  somewhat  in  excess  of  the  minimum  allowance  re- 
quired by  law.  ISTocht,  also,  is  of  the  opinion  that  internal  cleanli- 
ness and  a  more  judicious  arrangement  of  the  interior  of  the  living 
spaces  would  be  productive  of  greater  good  than  an  increase  in  the 
cubic  capacity  alone  would  be. 

Very  different  and  somewhat  more  complicated  and  diiScult  to 
understand  than  in  a  merchant  steamer,  are  the  various  divisions  and 
subdivisions  of  a  modern  first-class  battleship.  A  large  16,000-ton 
battleship,  complete  in  all  its  parts,  in  full  motion  and  in  action, 
approaches  perhaps  nearer  to  a  colossal  living  organism  than  any  other 
product  of  human  ingenuity  of  recent  date. 

To  begin  with,  everything  about  such  a  vessel,  that  can  be,  is 
made  of  steel  or  iron,  to  resist  not  only  the  waves  in  the  heaviest 
storms,  but  also  the  heaviest  armor-piercing  shot  and  shell.  Fig. 
38  is  intended  to  represent,  schematically,  the  main  divisions  of 
one  of  the  latest  types  of  a  first-class  battleship.  It  will  be  noticed 
that  the  thickest  line  in  the  drawing,  running  fore  and  aft  and  in- 
clining slightly  at  either  end,  divides  the  entire  ship  into  an  upper 
and  a  lower  half.  This  line  indicates  the  position  of  what  is  known 
as  the  protective  or  armored  deck.  All  the  other  decks  are  above 
the  protective  deck,  and  below  it  we  find  all  the  store-rooms,  boiler- 
rooms,  coal-bunkers,  engine-rooms,  steam-steering  rooms,  magazines, 
ammunition  passages,  and  trimming  tanks. 

The  different  decks,  from  alcove  downwards  and  extending  be- 
tween the  two  military  masts  are  the  bridge,  upper  deck,  main  deck, 
gun-deck,  protective  or  berth  deck;  with  a  flying  bridge,  situated 
above  the  bridge  around  the  forward  military  mast.  The  berth-deck 
proper  is  that  part  of  the  protective  deck  which  is  continued  in  an 
even  plane  forw^ard  and  aft  respectively  from  the  protective  deck,  from 
the  points  at  which  the  armored  deck  inclines  downward  for  a  short 
distance,  forming  an  acute  angle  with  the  berth-deck. 

As  a  general  rule,  all  the  men's  living  quarters  are  on  that  por- 
tion of  both  the  gun-deck  and  berth-deck  which  is  forward  of  the 
after  turrets,  while  the  officers'  quarters,  with  their  mess-rooms,  are 
on  the  same  decks  abaft  the  after  turret.  Iminediately  beneath  that 
part  of  the  armored  deck,  included  between  the  two  military  masts, 
are  the  engine-,  fire-,  and  dynamo-  rooms.  Forward  of  the  dynamo- 
room  and  abaft  the  engine-room  respectively  and  between  the  pro- 
tective deck  and  the  inner  bottom,  we  have  what  are  known  as  the 
upper  and  lower  platforms,  which  carry  stores  and  ammunition. 
Between  the   inner   bottom   and   the   outside  plating  there   are  the 


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(315) 


316  TEXT-BOOK  OF  HYGIENE. 

double  bottoms.  All  the  points  marked  W.T.  on  the  drawing  con- 
cern watertight  bulkheads. 

Fig.  33  represents  a  vertical  cross-section  from  the  same  type 
of  ship  as  the  preceding,  through  the  boiler-rooms;  the  decks  shown 
in  this  figure  are  the  same  as  those  shown  in  Fig.  38.  In  the  boiler- 
room,  to  the  left  of  the  reader,  may  be  seen  the  terminal  of  one  of 
the  large  ventilating  shafts,  of  the  usual  form,  ending  a  little  below 
the  plane  of  the  deck  above  and  quite  a  little  above  the  heads  of  the 
men.  The  lid  shown  in  the  figure  attached  to  its  lower  end  is  to  be 
closed  in  case  forced  draft  is  desired.  When  this  lid  is  closed,  the 
air  is  driven  by  the  adjoining  fan  in  a  direction  at  right  angles  to 
the  long  axis  of  the  shaft,  and  thence  down  into  the  boiler-room 
toward  the  furnaces,  where  it  is  intended  to  increase  the  combustion 
of  fuel  and  the  production  of  steam.  The  pressure  which  this  forced 
draft  arrangement  is  able  to  produce  is  said  to  be  equal  to  II/2  ounces. 
On  the  right  side  of  the  sketch  the  ventilating  terminal  is  shown  to 
have  a  different  arrangement.  Here,  the  air  is  purposely  shown  to  be 
carried  down  much  further  and,  moreover,  conducted  to  the  sides  of 
the  room  before  being  released  from  the  main  shaft.  The  figure 
was  intended  to  show  a  flattened  and  perforated  iron  casing  applied 
against  the  bulkhead  through  which  the  air  was  made  to  enter.  This 
arrangement  is  proposed  as  an  improvement  from  the  hygienic  stand- 
point, on  the  following  grounds :  In  the  first  place,  it  is  very  desir- 
able to  keep  the  cold  air  from  pouring  down  upon  the  heads  of  the 
stokers  and  firemen,  steeped  in  perspiration ;  and,  in  the  second  place, 
the  arrangement  will  give  the  admitted  air  a  chance  to  do  more  ven- 
tilating work  before  it  can  make  its  escape  through  the  centrally  lo- 
cated exhaust  pipe.  In  its  passage  from  the  sides  of  the  room  to  the 
center  it  passes  the  breathing  zone  of  the  men  at  work,  and  this  fur- 
nishes them  with  the  necessary  oxygen  before  escaping.  The  deeper 
down  the  cool,  imprisoned  air  is  carried  in  case  of  a  hot  room,  the 
greater  the  distance  which  it  will  have  to  make  while  it  becomes  hot 
and  rises,  and  the  greater  also  its  ventilating  work  will  be  before  it 
can  escape  again. 

Beneath  the  boiler-room  floor  the  figure  shows  some  of  the  drains. 
On  the  extreme  right  may  be  seen  the  large  main  drain,  nearest  the 
middle  line,  where  the  bilge  is  located,  there  are  the  two  independent 
bilge  suction-pipes.  The  secondary  drains,  as  well  as  the  double- 
bottom  floor  and  drain-pipes,  may  also  be  seen.  Fig.  33  represents  one 
side  of  a  vertical  section  through  the  ship,  where  the  eugine-rooms  are ; 
the  points  shown  in  this  figure  are  the  same  as  those  shown  in  the  pre- 
ceding. 


THE  SHIP.  317 

The  amount  of  cubic  air-space  for  the  living  quarters  of  the 
crew,  though  still  stingily  dealt  out  on  board  many  of  the  modern 
warships,  may  perhaps  be  regarded  as  all  that  can  be  expected  under 
the  present  strenuous  circumstances.  With  a  crew  of  from  six  to 
eight  hundred  men  on  a  battleship,  with  the  constantly  increasing 
number  of  officers  required  on  board,  and  the  ever-increasing  addi- 
tions in  new  apparatus  and  machinery  from  year  to  year,  the  con- 
structor of  such  a  ship  has  indeed  a  large  contract  on  hand,  if  he  is 
to  furnish  quarters  for  all,  that  are  to  be  satisfactory  from  all  points 
of  view.  From  the  point  of  view  of  sanitation,  of  course,  if  any  one 
thing  is  more  important  than  another,  that  thing  is  pure  air.  For 
no  one  can  study  thoroughly  the  history  of  sanitation  in  ships,  its 
gradual  and  slow  development  in  connection  with  life  at  sea  and  in 
ships,  without  coming  to  the  conclusion  that  human  overcrowding  or 
its  equivalent,  bad  air,  has  been  the  most  constant  and  ever-present 
factor  in  contributing  to  render  such  a  life  unhealthful.  Paradoxical 
as  it  may  seem,  it  is  nevertheless  a  fact  recorded  in  history,  that  men 
in  ships,  at  work  below  decks,  have  suffocated  from  want  of  air,  while  a 
gale  of  wind  was  blowing  outside.  The  recognition  by  ship-builders 
and  of  all  maritime  nations  of  the  present  day,  of  the  fact  that  a  cer- 
tain minimum  amount  of  cubic  air-space  should  be  allowed  every  living 
man  on  board  and  that  an  efficient  ventilation,  besides,  is  to  be  main- 
tained, may,  therefore,  with  excellent  reasons,  be  regarded  as  a  signal 
victory  over  the  conditions  of  the  past  and  as  the  most  important 
achievement  of  modern  marine  sanitation. 

Although  there  are  no  laws  in  existence  in  any  navy  with  regard 
to  the  cubic  air-space  to  be  allowed  per  man  on  board  a  warship,  such 
as  are  to  be  found  for  merchant  vessels  and  to  which  the  naval  con- 
structor or  commander  is  absolutely  obliged  to  conform,  the  neces- 
sity for  some  definite  allowance  is,  nevertheless,  so  urgent,  that  it 
practically  always  forms  one  of  the  important  factors  in  the  calcula- 
tions in  the  designs  for  every  new  vessel.  The  result,  of  course, 
as  might  be  expected,  is  not  a  uniform  one,  varying  with  the  indi- 
vidual ideas  of  the  designer,  all  the  way  from  2  to  5  cubic  meters, 
or  from  70  to  175  cubic  feet. 

Some  very  interesting,  as  well  as  instructive,  calculations  as  re- 
gards the  allowance  of  cubic  air-space  on  board  warships  have  been 
furnished  us  by  Dr.  C.  M.  Belli,  of  the  Royal  Italian  Navy,  quite 
recently.  Belli,  in  his  hygienic  report  on  the  second-class  battleship 
Varese,  has  calculated  with  great  exactness,  as  well  as  judgment,  the 
actually    available    air-space    per    man    under    different    conditions. 


ai8 


TEXT-BOOK  OF  HYGIENE. 


Making  due  allowance  for  the  number  of  men  occupying  the  different 
sleeping  quarters,  and  deducting  the  number  that  is  always  expected 
to  be  on  duty  in  other  parts  of  the  ship  under  the  usual  routine  in 
force,  and  which  latter  varies  in  accordance  with  the  whereabouts  of 
the  vessel  whether  in  port  or  at  sea,  he  arrives  at  the  conclusions 
shown  in  the  succeeding  table: — 


Table  XLVIII. 


Sleeping  Quarters 

O 

3 

Total  Cubic 
Air-space  in 
meters 

^      si 

Gun-deck,  forward    .  . 

30 

900 

6.66 

8  73 

13.33 

"       "      amidship  .  . 

300 

1,562 

5.20 

6.50 

10.40 

Berth  deck,  forward  .  . 

20 

161 

8.05 

10.60 

16.10 

"        "       amidship  . 

50 

452 

9.00 

11.30 

18.08 

"      aft    ...  . 

50 

234 

4.68 

5.80 

9.36 

Although  the  above  calculations  show  a  most  generous  provision 
of  air-space  and  speaks  well  for  the  sanitary  provisions  made  in  the 
Italian  Navy,  calculations  on  the  same  principles  as  those  made  by 
Dr.  Belli  on  other  warships  would  no  doubt  reveal  the  fact  that  the 
actually  available  breathing  space  for  the  men  is  greater  than  the  cal- 
culated air-space  is.  Notwithstanding,  however,  this  deduction,  it  is 
also  a  matter  of  exact  calculation  that  the  available  breathing-space 
on  some  of  our  own  vessels  does  not  come  up  to  one-half  of  the  al- 
lowance shown  in  the  above  table  as  existing  on  the  Varese. 

2.  Cleanliness. — Our  conception  of  the  term  "cleanliness"  in 
general  varies  quite  considerably  at  the  present  time  from  what .  it 
was  in  prebacterial  times.  While,  for  instance,  not  many  years  ago, 
the  surgeon  was  quite  confident  that  his  hands  were  clean  when  he 
had  scrubbed  them  in  soap  and  water,  continued  inquiry  and  investi- 
gation have  convinced  him  since  then  that  absolute  cleanliness  of  the 
hands  is  practically  unattainable.  The  methods  employed  for  pro- 
ducing absolute  cleanliness  of  persons  and  things  are  so  complex 
and  require  so  much  professional  knowledge  that  they  will  probably 
always  remain  in  the  possession  of  the  professional  few  and  never  be 
mastered  by  the  lay  masses. 

Not  long  ago,  a  ship,  for  instance,  was  considered  quite  clean 
when  its  decks  were  soaked  in  salt  water,  its  atmosphere  saturated 
with  moisture,  and  a  smell  of  turpentine  and  paint  permeated  the 
living  spaces.    After  an  expensive  experience  of  many  years,  we  have 


THE  SHIP. 


319 


•found  out  that  a  wet  ship  is  not  necessarily  a  clean  ship;  that  damp- 
ness on  board  a  ship  is,  indeed,  one  of  the  conditions  favoring  bac- 
terial growth  and  the  perpetuation  of  epidemics.  Still,  it  would  not 
be  hard  to  find  a  deck  officer,  even  at  the  present  day,  on  a  modern 
ship,  who  would  not  express  great  astonishment  if  told  that  his  clean- 
looking  ship  was  nevertheless  in  a  dangerously  unsanitary  condition. 
Much  missionary  work  is  yet  required  to  generalize  the  knowledge  of 
the  principles  of  ordinary  cleanliness. 

The  problem  of  cleaning  the  decks  of  a  ship  is  nearing  its  solu- 
tion on  those  vessels  in  which  linoleum  has  been  used  for  deck  cover- 
ing. Here,  the  daily  deluge  with  salt  water  has  ceased  to  be  neces- 
sary, and  a  moist  wiping  is  both  sufficient  and  effectual  in  producing 
the  ordinary  state  of  cleanliness.  The  atmosphere  between  decks 
has  become  much  drier  since  this  change  occurred.  But,  unfortu- 
nately, there  is  still  a  considerable  number  of  officers  in  the  service 
who  cannot  get  away  from  the  antiquated  system  of  giving  the  ship 
under  their  command  a  daily  "ducking,"  and  the  sanitarian,  there- 
fore, finds  it  still  necessary  sometimes  to  remonstrate. 

That  the  old  fight  for  dry  decks  was  really  founded  on  good  and 
sufficient  grounds  has  been  abundantly  shown  by  the  morbidity 
statistics.  Friedel,  quoted  by  Plimiert,  compared  the  morbidity  be- 
tween two  English  ships,  the  Centurio  and  the  Conqueror.  On  board 
the  former  none  but  dry  holy-stoning  was  practiced,  while  on  the 
latter  the  decks  were  scrubbed  after  the  usual  manner,  by  a  daily 
wetting  with  plenty  of  salt  water  and  a  more  thorough  weekly  one. 
The  morbidity  records  on  the  two  vessels  were  as  shown  in  the  suc- 
ceeding table : — 

Table  XLIX. 


Diseases                               • 

Centuro 

Conqueror 

Fevers 

4 

2 

132 

62 

'i89 

99 

Pneumonia 

Catarrh  of  respiratory  or,  ans 

Sore  throat 

33 

198 
179 

Dysentery 

Skin  diseases 

10 

257 

Summary 

389 

776 

The  medical  officer,  while  rarely  consulted  with  regard  to  the 
general  method  of  keeping  the  ship  clean,  is  often  asked  for  sugges- 
tions when  the  bilge  is  to  be  cleaned.  On  this  subject  he  should, 
therefore,  bo  able  to  give  expert  advice.     The  uKithod  of  treating  the 


320  TEXT-BOOK  OF  HYGIENE. 

bilge,  in  most  cases,  consists  in  a  combination  of  the  process  of  cleans- 
ing with  salt  water  with  some  process  of  disinfection. 

In  dealing  with  the  bilge,  it  is  by  no  means  an  indifferent  matter 
whether  the  contents  of  the  bilge  are  pumped  out  into  the  sea-water 
before  being  disinfected,  or  whether  their  disinfection  is  to  be  ef- 
fected first.  The  bilge-room  may  contain  infectious  germs  which  it 
is  not  safe  to  pass  on  into  the  waters  in  which  the  ship  lies  at  anchor. 
Then  again,  the  mixing  of  the  disinfectant  with  the  bilge-water, 
having  to  be  done  very  thoroughly  and  so  that  all  parts  of  the  bilge 
will  be  brought  into  intimate  contact  with  it,  it  will  make  consider- 
able difference  in  the  result  and  the  method  to  be  employed  whether 
the  ship  is  under  way  or  whether  she  lies  quietly  at  anchor.  When  in 
motion  all  parts  of  the  bilge-room  will  naturally  be  deluged  with  the 
disinfecting  fluid ;  when  at  anchor,  an  artificial  circulation  of  the  dis- 
infectant must  be  started  with  pumps  and  pipes.  The  fluid  from  the 
most  dependent  portion  of  the  bilge,  usually  aft,  must  be  pumped 
forward,  whence  it  runs  aft  again  by  simple  gravity,  and  thus  circu- 
lates through  the  entire  bilge  space. 

In  the  experiments  of  Koch  and  Gaffke  on  the  Freya  and  Hydne, 
the  disinfecting  fluid  was  first  mixed  with  the  bilge-water  and,  the 
ship  lying  quietly  at  anchor,  the  mixture  was  pumped  from  aft  forward, 
thus  causing  it  to  circulate  and  become  thoroughly  mixed.  After  this 
disinfected  bilge-water  had  been  pumped  out,  enough  disinfecting 
fluid  was  put  into  the  bilge-room  to  make  it  rise  to  the  same  level 
occupied  by  the  bilge-water  previously  disinfected  and  pumped  out. 

The  results  obtained  by  Koch  and  Gaffke  are  summed  up  in  the 
following  conclusions:  (1)  With  corrosive  sublimate  the  most  resist- 
ing bacilli  may  be  destroyed;  (2)  corrosive  sublimate  must  be  added 
to  the  bilge-water  in  sufficient  quantity  to  produce  the  reaction  of  mer- 
curic salt;  (3)  the  mixing  must  be  thorough;  (4)  the  disinfection 
may  be  regarded  as  accomplished  after  an  exposure  of  18  hours;  (5) 
after  the  bilge-room  has  been  rinsed  out  four  times,  the  amount  of 
mercury  remaining  behind  is  so  small  that  it  is  harmless.  The 
strength  of  the  solution  to  be  empioyed  is  7 :  2-3000  and  salt  water  is 
the  usual  solvent.  After  the  disinfection  the  bilge-room  is  dried  and 
its  floor  and  sides  covered  with  minium  paint.  In  the  German 
service  the  bilge  is  cleaned  in  this  manner  once  in  two  weeks. 

3.  Disinfection. — The  naval  surgeon  is  rarely  called  upon  to  su- 
perintend the  disinfection  of  an  entire  ship.  This  is  usually  done  at 
quarantine  stations,  where  the  necessary  appliances  and  machinery 
will  be  found  in  constant  readiness,  with  a  trained  personnel  to  run 


THE  SHIP.  321 

them.  There  are,  however,  many  minor  disinfections  to  be  done  on 
board  every  ship  which  the  ship's  surgeon  must  be  prepared  to  exe- 
cute, and  which,  to  do  them  well,  require,  nevertheless,  a  perfect 
knowledge  of  the  art  of  disinfection  and  its  practical  applications  in 
all  the  various  branches  on  his  part. 

While  in  civil  life  we  may  make  a  theoretical  distinction  between 
sanitary  science  and  hygiene,  or  between  a  mere  sanitarian  (whose 
duty  it  is  to  prevent)  and  the  hygienist  or,  in  this  case,  the  profes- 
sional disinfector  (whose  duty  it  is  to  remove  the  infection  after  it 
has  invaded  a  ship),  the  naval  surgeon  must  be  both  and  cannot  well 
afford  to  draw  a  strict  line  between  these  two  functions  if  he  is  to  do 
his  full  duty  by  his  command.  Besides,  the  whereabouts  of  war 
vessels  are  not  always  convenient  to  the  regular  disinfecting  stations. 

A  vessel,  especially  a  war  vessel,  is  rarely  so  badly  infected  as 
to  need  a  disinfection  throughout.  There  is  no  more  reason  for  fumi- 
gating the  hold  of  any  vessel  because  a  case  of  measles  has  appeared 
in  the  cabin  or  the  steerage,  than  there  is  for  disinfecting  the  base- 
ment of  a  tenement  on  account  of  the  appearance  of  a  case  in  one 
of  the  upper  stories  of  the  building.  In  a  wooden  vessel  or  iron  mer- 
chant ship,  with  free  communications  between  the  various  compart- 
ments, the  danger  of  spreading  any  contagion  throughout  all  parts  of 
the  ship  is,  of  course,  very  great,  but  on  a  battleship,  for  instance, 
with  its  two  hundred  separate  compartments,  this  danger  is  consider- 
ably less  apparent. 

Of  the  utmost  importance,  however,  is  it  to  choose  the  proper 
method  in  special  cases.  In  this  respect,  the  naval  surgeon  finds 
himself  frequently  in  a  difficult  position  because  of  being  obliged  to 
devise  both  the  means  and  the  apparatus  in  order  to  gain  his  ends. 
He  will  then  realize  that  nothing  short  of  a  thorough  preliminary 
training  in  the  principles  and  practice,  of  the  art  can  ever  help  him 
out  of  the  difficulty. 

Sometimes,  the  composition  of  the  vessel  to  be  disinfected  will 
determine  the  choice  of  the  method.  A  wooden  vessel,  for  example, 
requires  a  most  thorough  mechanical  cleansing  and  a  longer  exposure 
to  germicidal  agents  than  an  iron  one,  in  order  to  insure  penetration 
and  thorough  disinfection,  on  account  of  the  spongy  nature  of  the 
wood,  as  compared  with  the  smooth  surfaces  of  iron  plates. 

It  is  sometimes  of  as  much  importance  to  know  what  to  disin- 
fect as  how  to  do  it.  Thus,  the  cargo  of  a  vessel  is  rarely  infected 
except  in  case  of  plague,  where  the  rats  carry  the  infection  into  the 
deepest  parts  of  the  ships  and  bilges.     The  rats  must  be  thoroughly 

21 


322  TEXT-BOOK  OF  HYGIENE. 

destroyed,  and  after  their  destruction  so  handled  that  the  infection 
cannot  spread  from  the  cadavers.  In  the  disinfection  of  living  spaces 
it  should  always  he  rememhered  that  metal  and  all  hright  work  are 
ruined  by  sulphur  and  bichloride  and  that,  therefore,  the  use  of  for- 
maldehyde and  carbolic  acid  must  be  resorted  to  instead.  In  using 
steam  it  must  be  kept  in  mind  that  leather  and  furs  are  ruined  by  it. 
When  water-tanks  are  suspected  of  harboring  the  larvae  of  mosquitoes 
and  the  ship  happens  to  be  in  salt  water,  the  water  may  safely  be 
pumped  out,  because  the  larvae,  neither  of  anopheles  nor  of  stegomyia, 
ever  develop  in  salt  water.  When,  however,  the  ship  is  in  sweet 
water,  petroleum  should  be  first  employed.  In  case  the  water-tanks 
are  infected  with  the  germs  of  cholera,  typhoid,  or  dysentery,  the 
water  in  them  should  in  all  cases  be  thoroughly  disinfected  or  boiled 
by  steam.  A  vessel  kno-mi  to  be  infected  with  yellow  fever  should 
always  be  given  a  preliminary  fumigation  with  sulphur  or  pyrethrum 
powder,  before  being  inspected,  in  order  to  either  kill  or  benumb  the 
infected  insects  and  thus  protect  the  inspectors. 

On  the  broadest  general  principles,  while  steam  and  formaldehyde 
must  be  considered  the  best  agents  for  the  disinfection  of  bedding  and 
clothing,  as  well  as  living  spaces,  there  are  a  number  of  infectious 
diseases  that  require  special  treatment  and  consideration.  Thus,  dur- 
ing epidemics  of  cholera  special  vigilance  must  be  kept  upon  the 
water  supply  and  the  pipe  connections ;  in  case  of  plague,  it  is  to  rats 
that  we  must  pay  special  attention;  in  yellow  fever,  certain  species 
of  mosquitoes  must  be  destroyed ;  in  ease  of  the  exanthems,  bedding, 
clothing,  and  the  patient's  skin  must  receive  the  lion's  share  of  our 
efforts.  In  all  cases  alike,  the  ship's  decks  must  be  disinfected,  since 
Belli  has  shown  in  an  experimental  study  that  the  ordinary  methods 
of  scrubbing  with  either  salt  water  or  lye,  as  is  commonly  done,  does 
not  expedite  the  disappearance  of  infectious  germs. 

The  most  important  disinfecting  agents  that  should  be  kept  on 
hand  aboard  every  sea-going  vessel  are  sulphur,  steam,  formaldehyde, 
lime,  bichloride  of  mercury,  and,  of  late,  coke  must  be  added  to  the 
list.  Sulphur,  for  some  time  in  disrepute,  on  account  of  its  lack  of 
penetrating  power  and  its  failure  to  kill  spore-bearing  germs,  has  re- 
cently regained  part  of  its  lost  prestige,  since  it  became  known  that 
it  kills  mosquitoes  and  other  disease-bearing  animal  parasites.  The 
best  method  for  ships'  use  is  the  iron-pot  method.  The  sulphur  U 
usually  used  in  lumps  that  are  saturated  with  alcohol  and  then  lit. 
Five  pounds  of  sulphur  for  each  1000  culiic  feet  of  air-space  pro- 
duce a  5  per  cent,  gas,  which  is  sufficient  to  kill  all  non-spore-bearing 


THE  SHIP.  323 

organisms  within  sixteen  hours.  Care  should  be  taken  that  the  articles 
to  be  treated  by  this  method  are  not  too  dr3\ 

Steam  is  perhaps  the  most  widely  used  disinfecting  agent,  as 
well  as  the  most  valuable  of  any  used  on  board  ships.  Steam-pipes 
may  be  found  conveniently  located  in  almost  any  part  of  a  ship,  and 
can  be  tapped  for  a  supply  of  steam.  In  case  no  regular  steam  dis- 
infecting apparatus  is  at  hand,  such  an  apparatus  may  be  extemporized 
and  made  out  of  a  vinegar  or  wine  barrel  or  some  iron  water-tank. 
Streaming  steam  has  the  same  power  as  boiling  water,  and  an  exposure 
of  half  an  hour  is  generally  sufficient  to  kill  very  resisting  spores. 
It  may,  therefore,  safely  be  used  and  depended  upon  for  destroying 
the  infectious  agents  of  any  of  the  communicable  diseases.  It  should 
be  remembered  that  steam  shrinks  woolens  and  injures  silks,  it  ruins 
leather,  fur,  skins  of  all  kinds  also  rubber  shoes,  mackintoshes,  and 
other  articles  of  impure  rubber. 

Formaldehyde. — A  gas  is,  of  course,  the  ideal  form  of  a  disinfect- 
ant, and  formaldehyde  comes,  perhaps,  nearer  to  that  ideal  than  any 
other  gas,  in  spite  of  the  fact  that  it  has  some  very  decided  limitations, 
not  the  least  of  which  is  its  lack  of  penetrating  power.  Solutions, 
unless  immersion  can  be  maintained  for  a  long  enough  time  without 
injury  to  the  material,  are  not  so  valuable.  Several  years  ago,  von 
Esmarch  devised  a  method  by  means  of  which  it  was  thought  possible 
to  eliminate  the  shortcomings  of  both  steam  and  formaldehyde.  The 
method  aimed  at  a  combination  of  steam  and  formaldehyde  in  a 
chamber  in  which  the  air  was  rarified  at  the  same  time.  By  adding 
the  vapor  of  formaldehyde  to  steam  it  was  hoped  that  steam  might  be 
used  at  a  lower  temperature  than  100°  C,  and  thus  its  injurious  ef- 
fects on  some  of  the  fabrics  be  eliminated.  By  causing  a  partial 
vacuum  in  the  disinfecting  chamber  it  was  hoped  that  the  penetrat- 
ing effect  of  formaldehyde  could  be  materially  increased.  Ivister  and 
Trautmann,  in  some  recent  experiments  with  von  Esmarch's  method. 
made  with  the  object  of  testing  its  applicability  on  a  large  scale,  ob- 
tained results  that  were  not  quite  as  promising  as  they  had  been  led  to 
expect.  Although  the  combination  of  steam  with  a  3  per  cent,  atmos- 
phere of  formaldehyde  gave  evidence  of  increased  disinfecting  power, 
it  was  noted  that  the  m.ixture,  at  a  temperature  of  75°  C.  and  under 
a  reduction  of  the  pressure  equal  to  520  millimetres,  failed  to  kill 
all  the  spores  and  did  not  uniformly  penetrate  all  parts  of  the  cham- 
bers. The  method,  however,  seems  promising,  and  its  further  perfec- 
tion will  be  only  a  matter  of  time. 

Formaldehyde  occurs  in  the  market  in  several  forms.    The  40  per 


324  TEXT-BOOK  OF  HYGIENE. 

cent,  solution  is  known  as  formalin,  and  this  is  sometimes  used  for 
the  generation  of  the  gas  in  a  special  generator.  Ten  ounces  of  this 
fluid  are  considered  quite  sufficient  for  each  1000  cubic  feet  of  air-space. 
Sometimes  the  gas  is  developed  directly  from  wood  alcohol.  When  the 
vapor  of  wood  alcohol  is  passed  over  incandescent  platinum,  the  alco- 
hol is  reduced  to  an  aldehyde.  By  the  use  of  the  Kuhn  lamp  three 
pints  of  wood  alcohol  may  be  reduced  in  two  hours,  and  the  amount 
of  gas  thus  produced  is  said  to  be  sufficient  for  the  disinfection  of 
1000  cubic  feet  of  space.  For  the  purpose  of  disinfecting  clothing 
in  a  trunk,  which  often  needs  to  be  done  when  officers  return  from 
leave  of  absence  and  report  infectious  diseases  in  their  families,  not 
less  than  50  cubic  centimetres  of  formalin  for  each  cubic  foot  of 
space  is  required.  (Eosenau.)  Mail  matter  is  ordinarily  disinfected 
by  clipping  the  corners  off  the  envelopes  and  introducing  a  few  drops 
of  formalin  with  an  eye-dropper,  and  several  drops  are  also  put 
on  the  outside  cover  and  the  whole  shut  up  in  a  tight  box,  which 
is  then  placed  in  a  warm  room  for  six  hours.  The  box  should 
be  opened  out  of  doors.  Formalin  is  also  a  convenient  disinfect- 
ant for  urine,  excreta,  and  sputum,  because  of  its  possessing  the 
property  of  combining  with  the  albuminous  matters  without  causing 
their  coagulation.  On  account  of  its  nontoxic  properties  it  is,  more- 
over, often  employed  in  the  disinfection  of  food-products.  Large 
quantities  of  bulbs,  roots,  nuts,  fruits,  and  similar  articles,  coming 
from  infected  districts,  are  treated  by  immersion  into  a  5  per  cent, 
solution  of  formalin  without  harm.  Bulbs  so  treated  keep  from 
rotting  for  a  long  time. 

Lime. — Milk  of  lime,  which  is  slaked  lime  mixed  with  about  four 
times  its  volume  of  water,  is  one  of  the  most  useful  disinfectants 
for  excreta  and  privy-vaults.  Chlorinated  lime,  in  the  United  States 
Army  officially  prescribed  in  the  form  of  a  4  per  cent,  solution  for 
use  in  the  disinfection  of  the  excreta  from  the  sick,  combines  the  effect 
of  both  lime  and  chlorine.  When  used  for  ships'  holds  or  rooms,  l^/o 
pounds  of  it  mixed  with  6  ounces  of  strong  sulphuric  acid  are  supposed 
to  be  sufficient  to  produce  the  purification  of  1000  cubic  feet  of  space. 
As  is  the  case  with  sulphurous  acid,  chlorine  gas  acts  more  energetically 
in  the  presence  of  moisture. 

Mercuric  Chloride. — One  of  the  most  popular  of  the  disinfect- 
ants is  mercuric  chloride.  A  solution  of  1 :  1000  will  surely  kill  all 
spore-bearing  organisms  at  ordinary  temperature  within  half  an  hour. 
Articles  of  clothing  may  be  thoroughly  disinfected  by  immersion  into 


THE  NAVY  RATION.  325 

a  solution  of  1 :  2000  for  two  hours;  a  solution  of  1 :  15,000  inhibits 
both  fermentation  and  putrefaction. 

Carbon  Monoxide. — In  carbon  monoxide  we  possess  one  of  the 
most  efficient  gases  for  the  destruction  of  rats  in  ships.  Nocht  and 
Giemsa  have  recently  devised  an  ingenious  apparatus  in  which  the  gas 
is  produced  by  the  incomplete  combustion  of  coke.  Part  of  the  heat 
produced  by  the  combustion  is  used  to  furnish  the  steam  necessary 
for  running  a  water-pump  and  ventilator.  The  gases  resulting  from 
the  combustion  of  coke  are  heavily  charged  with  carbon  dioxide,  the 
pressure  of  which  prevents  them  from  forming  an  explosive  compound 
when  mixed  with  air.  This  protective  action  of  CO,  is  secured  when  the 
latter  reaches  an  amount  equal  to  twice  that  of  the  carbon  monoxide 
content.  As  determined  by  the  apparatus  of  Orsat,  the  composition 
of  the  gaseous  mixture  produced  in  the  generator  is  CO,  4.95  per 
cent. ;  COg,  18  per  cent. ;  and  N.,  77.05  per  cent,  by  volume.  Four 
hundred  and  five  cubic  metres  of  the  gas  can  be  produced  in  one  hour. 
The  gas  has  a  specific  gravity  of  1085.  Before  beginning  the  disin- 
fection the  men  must  leave  the  ship.  In  order  to  kill  all  the  rats  in 
a  ship,  it  suffices  to  generate  an  amount  of  gas  which  equals  one-half 
to  three-quarters  the  capacity  of  the  ship.  The  process  of  disin- 
fection being  over,  all  that  is  necessary,  in  order  to  get  rid  of  the  gas, 
is  to  start  the  ventilators  and  open  the  hatches.  This  may  be  done 
after  an  exposure  of  six  hours. 

Mice  are  used  for  testing  the  atmosphere  for  CO.  These  ani- 
mals, which  are  very  sensitive  to  CO,  must  be  found  alive  after  a  two- 
hours'  residence  in  any  compartment,  before  the  ship  is  pronounced 
safe  for  re-occupancy.  The  method  is  not  only  reliable  and  thorough, 
but  also  quite  inexpensive. 

THE    NAVY   RATION. 

While  it  cannot  be  expected,  in  the  limited  space  allotted  to  this 
article,  that  we  enter  at  all  into  the  special  physiology  of  nutrition 
or  into  the  chemistry  of  food-stuffs,  it  is,  on  the  other  hand,  unavoid- 
able and  necessary  to  touch  upon  those  of  the  leading  principles  and 
methods  according  to  which  the  nutritive  values  of  those  of  the  food- 
substances  that  are  in  common  use  on  board  sea-going  vessels,  and 
included  in  the  navy  ration,  are  ordinarily  determined. 

In  the  ordinary  walks  of  life  a  man  chooses  not  only  what  articles 
he  eats,  but  also  how  much  of  these  he  thinks  he  needs,  and  the  free 
play  of  his  instincts  generally  leads  him  to  select  from  a  bill-of-fare 
the  diet  best  adapted   for  his  maintenance.     In   naval  and  military 


326  TEXT-BOOK  OF  HYGIENE. 

organizations  tliis  free  choice  or  selection  as  regards  a  man's  diet  is 
greatly  limited,  inasmuch  as  the  latter  is  provided  for  him  by  some 
one  else.  Hence  it  will  readily  be  seen  how  very  important  it  is  that 
this  provided  diet  should  answer  in  all  respects  to  the  full  require- 
ments of  the  average  working  man. 

The  diet-list  made  out  on  board  ship  ought  to  differ,  therefore, 
from  an  ordinary  bill-of-fare,  in  giving,  upon  careful  examination,  the 
results  characterizing  a  perfectly  constructed  and  in  every  respect 
complete  meal.  The  meals  for  the  day,  to  be  called  perfect,  must 
show  that  they  contain  in  proteids,  fats,  and  carbohydrates  not  only 
the  proper  amounts,  but  also  the  right  relative  proportions  of  each. 
When  the  examination  shows  that  this  is  the  case,  then  our  list  of 
articles  ceases  to  be  a  mere  ''bill-of-fare"  and  becomes  a  ''ration/' 
intended  to  meet  all  the  required  needs  of  the  normal,  working  human 
organism  for  a  period  of  twenty-four  hours.  Since  the  distribution  of 
the  different  articles  of  food-stuffs,  on  board  ship,  at  any  rate,  is  left 
to  the  commissary  yeoman,  a  man  not  generally  in  possession  of  the 
knowledge  required  to  perform  that  duty  according  to  the  best  prin- 
ciples of  the  physiology  of  nutrition,  and  since,  moreover,  the  influ- 
ence of  the  continuous  faulty  distribution  of  food-stuffs  upon  the 
larger  number  of  men  must  prove  disastrous  in  the  long  run,  it  be- 
hooves the  sanitary  officer  to  keep  an  eye  on  the  diet  of  his  men  and 
correct  any  mistake  made  in  this  respect.  He  should,  therefore,  be 
familiar  with  the  methods  employed  to  determine  the  food  values  of 
any  diet,  as  well  as  know  when  a  diet  is  complete  in  all  respects,  and 
when  it  is  not. 

The  food  value  of  any  edible  substance  is  generally  expressed 
by  the  number  of  calories  or  heat  units  which  one  gram  or  any  other 
definite  quantity  of  it  will  develop  when  completely  burned  in  a 
calorimeter.  The  amount  of  heat  that  is  developed  during  the  com- 
bustion, for  instance,  of  one  gram  of  a  substance  in  a  calorimeter  is 
exactly  the  same  that  is  produced  when  one  gram  of  the  same  sub- 
stance is  completely  oxidized  within  the  body.  In  a  living  organism 
about  30  per  cent,  of  this  value  can  be  put  out  in  the  form  of  me- 
chanical work,  while  the  remainder  passes  off  in  the  form  of  heat. 
We  know,  thanks  to  the  researches  of  Voit,  that  an  average  adult 
laborer  performing  his  daily  work  puts  out  in  mechanical  work  and 
heat  the  equivalent  of  about  3000  calories.  In  order,  therefore,  that 
the  man  shall  not  lose  his  weight,  his  daily  diet  must  be  such  as  to 
balance  his  loss  and  have  a  combined  caloric  value  of  at  least  3000 
units.    If  we  furthermore  take  into  calculation  that  about  400  of  these 


THE  NAVY  RATION.  327 

units,  at  least,  must  come  from  proteids,  500  from  fats,  and  the  re- 
mainder from  carbohydrates,  we  have  the  most  necessary  data  for 
the  calculation  of  the  man's  diet.  Thanks  to  the  labors  of  Voit  and 
Eubner  and  their  numerous  pupils,  these  determinations  have  been 
greatly  simplified  in  recent  years. 

Outside  conditions,  personal  and  racial  habits,  climate,  age,  and 
sex  may  alter  the  relative  proportions  of  proteids,  fats,  and  carbo- 
hydrates in  a  certain  diet;  but  the  above  proportions  must  stand  as 
answering  to  the  average  requirements  of  an  adult  workingman  in 
a  temperate  climate.  In  calculating  the  dietary  value  of  a  ration  we 
must  also  allow  for  an  unavoidable  loss  in  the  preparation  of  the  differ- 
ent parts  of  it.  In  meats  a  loss  of  20  per  cent,  of  the  raw  material  is 
generally  allowed  for  bones;  in  salted  herring,  37  per  cent. ;  in  pickled 
herring,  29  per  cent.  Potatoes  boiled  and  then  peeled  lose  7  per  cent. 
Potatoes  peeled  raw  lose  30  per  cent.  In  the  case  of  eggs  10  per  cent, 
in  weight  is  deducted  for  the  shells,  etc.  Another  source  of  loss  from 
the  gross  weights  is  in  the  different  degrees  of  digestibility  of  foods, 
for  which  allowance  must  also  be  made.  As  a  general  rule,  animal 
foods  are  much  more  completely  digested  than  foods  of  vegetable 
origin.  Eubner  has  shown  that  the  proteids  from  meat  and  milk  dis- 
appear almost  entirely,  while  those  from  bread,  and  especially  vege- 
tables, reappear  in  the  feces  in  considerable  proportions. 

A  simple  and  approximately  accurate  method  for  calculating  the 
nutritive  value  of  a  diet  has  recently  been  published  by  Schumburg. 
He  makes  a  slight  difference  in  the  food  value  between  animal  and 
vegetable  proteids,  giving  the  former  a  value  of  3.5  and  the  latter  a 
value  of  3.1.  The  fats  have  a  value  of  8.8  and  the  carbohydrates  one 
of  3.7.  Given,  then,  the  various  constituents  of  a  diet,  expressed  in 
proteids,  fats,  and  carbohydrates,  their  weight  stated  in  grammes, 
multiplied  by  their  respective  values,  the  several  amounts  added  to- 
gether would  give  a  sum  corresponding  to  the  total  food  value  of  a 
diet  in  numbers  of  calories  or  nutrient  units.  Kemembering  that  a 
sufficient  diet  for  an  adult  workingman  must  have  at  least  2000 
nutrient  units,  and  that  the  proportion  of  proteids,  fats,  carbohydrates, 
and  salts  in  a  complete  diet  should  be  as  150,  100,  500,  and  35,  we 
should  have  an  easy  and  simple  method  of  ascertaining  and  con- 
trolling the  dietary  value  of  any  meal. 

It  is  on  these  principles,  and  with  the  aid  of  the  usual  tables  of 
the  food  values  of  the  different  articles  entering  into  the  composition 
of  a  diet  to  be  found  in  every  work  on  physiology  or  hygiene,  that 
the  following  diet  table  of  the  new  naval  ration  has  been  worked  out. 


328 


TEXT-BOOK  OF  HYGIENE. 


A  reduction  of  about  35  per  cent,  of  the  quantity  of  every  article 
in  the  table,  with  the  exception  of  the  usual  quantities  of  bread,  but- 
ter, coffee,  milk,  and  sugar,  was  made  for  certain  necessary  and  un- 
avoidable waste  which  occurs  in  their  preparation.  In  calculating  the 
food  values  of  the  customary  quantities  of  bread,  butter,  coffee,  milk, 
and  sugar  which  are  served  out  at  every  meal,  the  value  of  coffee  as  a 
food  was  disregarded.  It  may  be  added  that  the  coffee  is  replaced, 
especially  for  supper,  by  cocoa  or  tea. 

Table  L. 

Diet  table  prepared  from  one  wee¥s  allowance  of  the  neio  United  States  naval  ration. 

SUNDAY. 


Weight 

in 
Grams 

Contents  in  Grams 

In  Nutrient  Units 

Food  Allowed 

Protein 

Fats 

Carbohy- 
drates 

ProteiQ 

Fats 

Carbohy- 
drates 

Sum. 

Breakfast: 
Baked  beans 

135 
90 

32.8 
15.8 

2.0 

19.8 

66.2 

101.7 
55.3 

17.6 
174.2 

244.9 

364.2 
229  5 

Pork 

Catsup 

16.8 

19.9 

170.7 

52.6 

175.1 

631.6 

859.3 

Sum 

209.6 

366.9 

876.5 

1  453  0 

Dinner : 
Roasted  veal 

360 
270 

72.2 
5.4 

32.4 
.5 

252.7 
16.7 

285.1 
4.4 

537  8 

Potatoes,  mashed. . . . 
DressinR 

55.9 

206.8 

227.9 

16.8 

19.9 

1:0.7 

52.6 

175.1 

631.6 

859.3 

Sum 

1 

t 

322  0 

464.6 

8  8.4 

1  625  0 

Supper: 
Ham,  boiled 

1^0 
112 

27.5 

.2 

16.8 

r2.o 
"19.9" 

96.2          457.6 

.6      

52.6          175.1 

553  8 

J.lly 

36  0 
170.7 

133.2 
631.6 

133  8 

859  3 

Sum 

149.4 

632.7 

764.8 

1,546.9 

Total  nutrient  units  in  day's  ration,  4,625. 

MONDAY. 


Breakfast : 

90 
ISO 

10.8 
17.1 
16.8 

4.0 
136.8 
19.9 

5  .2 

33.5 
63.3 
52.6 

35.2 

1  203.8 

175.1 

19.3.1 

261  8 

Bacon,  fried 

1  267  1 

1:0.7 

631.6 

859  3 

Sum 

149.4 

1,414.1 

824.7 

2  388  2 

Dinner : 
Beef,  roasted 

360 
1£0 

80  3 
41.0 

IK.  8 
7.2 

102.9 

3.2 

19.9 

.7 

281.0 
127.1 
52.6 
22.3 

90.3.5 

28.2 

175.1 

6.2 

1 186  5 

94.3 
170.7 
74.5 

348.9 
631.6 
275.6 

504  2 

Bread,  butter,  etc. . . . 

859  3 

Potatoes 

360 

304.1 

Sum 

483.0 

1,11.5.0 

1,256.1 

2  854  1 

Supper : 
Cold  beef. 

ISO 

10 
iO 

40.1 

11.7 

.4 

16.8 

51.5 
1.8 

"lb.  9" 

140.3 

36.3 
1.2 
52.6 

453.2 
15.8 

"iVs'.i' 

593  5 

Pudding- 

m.3 

86.8 
170.7 

522.8 
323.2 
631.6 

574  9 

324  4 

Bread,  butter,  etc. . . . 

859  3 

Sum 

230.4 

644.1 

1,477.6 

2,352.1 

1 

Total  nutrient  units  in  day's  rations,  7,594.4. 


THE  NAVY  RATION. 


329 


Table  L  — (Continued.) 

Diet  taUe  prepared  from  one  week^s  allowance  of  the  new  United  States 
naval  ration. 

TUESDAY. 


Weight 

in 
Grams 

Contents  in  Grams 

In  Nutrient  Units        1 

Food  Allowed 

Protein 

Fats 

Carbohy- 
drates 

Protein 

Fats 

Carbohy- 
drates 

Sum. 

Breakfast : 
Hash— 

180 
345 

"     45 

27.5 

6.9 

.8 

16.8 

52.0 
.7 
.1 

96.2 

21.4 

2.5 

52.6 

172.7 

457.7 

6.2 

.8 

175.1 

553.8 

71.4 
4.6 

264.2 

17.0 

631.6 

291.8 

20.3 

19.9     1     170.7 

859.3 

639.7 

912.8 

1,725.2 



Dinner : 
Soup — 

90 

360 

45 

90 

21.9 

63.0 

.6 

1.4 

79.2 

.1 

44.1 

67.9 
220.5 

1.8 

12.3 

697.0 

.8 

163.2 

243.4 

Pork 

917.5 

Tomatoes 

2.0 

7.4 

10.0 

16.8 

19.9     1     170.7 

52.6 

175.1 

631.6 

859.3 

342.8 

885.2 

802.2 

2,030.2 

Supper  : 
Stew— 

360 
90 
15 
45 

180 

6.8 
7.8 

'    '".2" 
40.1 
16.8 

1.2 

.9 

12.2 

'  51.5' 
19.9 

11.9 
67.0 

21.0 
24.2 

10.6 

7.9 
107.4 

'  453.2' " 
175.1 

44.0 
247.0 

75.6 

279.1 

107.4 

43.4 

.6 

140.0 

52.6 

161.6 

162.2 

593.2 

170.7 

631.6 

859.3 

Sim 

238.4 

754.2 

1,034.2 

2,076.8 

1 

Total  nutrient  units  in  day's  ratidn,  5,832. 


WEDNESDAY. 


Breakfast : 

180 
90 

43.8 
15.8 

2.8 
19.8 

88.2 

135.8 
55.3 

24.6 
174.2 

326.3 

486.7 

Pork 

229.5 

16.8 

19.9 

170.7 

52.6 

175.1 

631.6 

859.3 

*            

243.7 

373.9 

957.9 

1,575.5 

Dinner: 
Sausages  (Frankfort) . 

225 
500 
270 
180 

39.4 
8.0 
3.5 
3.5 

16.8 

90.0 

1.5 

.5 

.4 

19.9 

1S7.9 

24.3 
10.8 
10.8 
52.6 

792.0 
13.2 
4.4 
3.5 

175.1 

929.9 

28.0 

21.9 

37.3 

170.7 

103.6 

81.0 

138.0 

631.6 

141.6 

96.2 

152.3 

859.3 

236.9 

988.2 

954.2 

2,179.3 

Supper : 

110 

45 

10 

45 

110 

9.9 
14.0 

24.5 
16.8 

.5 

11.0 

8.4 

.1 
31.6 
19.7 

84.7 
1.0 

30.7 
49.0 

4.4 

96.8 

73.9 

.8 

278.0 

175.1 

313.4 
3.7 

348.5 

149.5 

73.9 

2.0 

1.5 

85.7 
52.6 

7.4 

9.7 

Beef,  comed 

363.7 

170.7 

631.6 

859.3 

219.5 

629.0 

956.1 

1,804.6 

Total  nutrient  units  in  day's  rations,  5, .5.59. 4. 


330 


TEXT-BOOK  OF  HYGIENE. 


Table  L. —  {Continued.) 

Diet  table  prepared  from  one  week^s  allowance  of  the  new  United  States 
naval  ration. 

THURSDAY. 


Weight 

in 
Grams 

Con 

tents  in 

Grams 

In  Nutrient  Units 

Food  Allowed 

Protein 

Fats 

Carbohy- 
drates 

Protein 

Fats 

Carbohy- 
drates 

Sum. 

Breakfast : 
Slew- 
Beef  

1?0 

270 

45 

30 

25 

40.1 
5.5 
.6 
.4 
.3 

16.8 

51.5 
.5 
.2 

19.9" 

140.0 

17.0 

1.5 

1.5 

1.0 

52.fi 

453.2 
4.4 
1.7 

'  175.  i' ' 

593  2 

Potatoes    

Carrots 

5.5.9 
5.0 
3.0 
1.0 
170.7 

206.8 

18.5 

11.1 

3.7 

631.6 

228.2 
21.7 
12  6 

4  7 

859.3 

213.6 

634.4 

871.7 

1,719.7 

Dinner: 

360 
110 
135 
180 

56.1 
1.8 
L7 
3.5 

16.8 

94.3 
.1 
.3 
.4 

19.9 

196.0 

6.0 

5.5 

in.  8 

52.6 

829.8 

.8 

3.0 

3.5 

175.1 

39!  5" 

40.7 
1.38.0 
631.6 

1,025.8 
46.3 

Beets    

10.7 

11.0 

37.3 

170.7 

49.2 

152  3 

859  3 

1 

1,012.2 

849.3 

2,132.9 

,„ 

Supper : 
Rice 

110 

72 
80 

7.2 

6.0 

.4 

1.1 
6.0 

86.4 

22.3 

21.0 

1.2 

9.6 

52.8 

819.6 

351.5 

EgM 

73  8 

77.2 

285.6 

286.8 

Beef,  corned,  c  Id  . . . 

135 

21.0 
16.8 

35.4 
19.9 

73.5 
52.6 

311.5 
175.1 

385.0 

170.7 

631.6 

859  3 

270.6 

549.0 

1,236.8 

1,956.4 



Total  nutrient  units  in  day's  ration,  5,809. 


FRIDAY. 


Breakfast : 
Ham 

180 

315 

22 

27.5 

6.3 

.1 

16.8 

52.0 
.6 

"19.9" 

96.2 

19.5 

.3 

52.6 

451.6 
4.4 

'  175.1" ' 

547  8 

65.2 

2.0 

170.7 

241.2 

7.4 

631.6 

265  1 

7  7 

859.3 

168.6 

631.1 

880.2 

1,679  9 

Dinner  : 

Mutton,  roasted 

Peas 

360 

180 

16 

360 

273.6 

41.0 

1.2 

7.2 

16.8 

61.2 

3.2 

1.3.8 

.7 

18.9 

21.6 

94.3 

.1 

74.5 
170.7 

957.6 

127.1 

4.0 

22.3 

52.6 

544.0 

28.1 

118.8 

6.1 

175.1 

79.9 

347.8 

.3 

277.6 

631.6 

1,581.5 
503  0 

Butter 

1231 

Potatoes,  mashed 

306.0 
859.3 

Sum 

1,163.6 

872.1 

1,337.2 

3  372  8 

Supper : 
Salmon 

270 
90 

57.2 

.7 

16.8 

34.6 
'  19.9' ' 

2C0.2 
1.4 
52.6 

304.5 
'  175.1'  ■ 

504  7 

Fruit,  canned 

7.2 
170.7 

26.6 
631.6 

2  .0 
859.3 

Sum 

254.2 

479.6 

658.2 

1  392  0 

Total  nuirient  unils  in  day's  ra'ion,  6,444.8. 


THE  NAVY  RATION. 


331 


Table  L. — {Continued.) 

Diet  table  prepared  from  one  week's  allowance  of  the  new  United  States 
naval  ration. 

SATURDAY. 


Weight 

in 
Grams 

Contents  in  Grams 

In  Nutrient  Units 

Food  Allowed 

Protein 

Fats 

Carbohy- 
drates 

Protein 

Fats 

Carbohy- 
drates 

Sum. 

Breakfast : 
Soup— 

180 
270 
70 
20 
00 

136.8 

5.4 

.8 

.3 

1.2 

16.8 

30.6 
.5 
.3 
.1 
.2 

19.9 

10.8 

55.9 

6.4 

2,0 

8.0 

170.7 

478.8 

16.8 

2.4 

.3 

3.7 

52.6 

269.3 

4.4 

2.6 

.8 

22 

175.1 

40.0 
207.2 

23.6 
7.4 

29.6 
631.6 

788.1 

Potatoes 

28.6 

35.5 

Bread,  butler,  etc 

Sum 

554.6 

454.4 

639.4 

1,948.4 

Dinner : 
Beans 

70 

360 

50 

17.0 

63.0 

.6 

16.8 

1.0 

79.2 

.1 

19.9 

34.3 

52.1 

220.5 

1.5 

52.6 

8.8 

685.2 

.8 

175.1 

126.9 

187.8 
905.7 

Pork 

Tomatoes 

Bread,  butter,  etc 

2.0 

170.7 

7.4 
631.6 

9.7 
859.3 

Sum 

323.7 

869.9 

765.9 

1,962.5 

Supper : 

ISO 
90 

31.5 

26.5 

16.8 

72.0 
21.6 
19.9 

110.2 

92.4 
52.6 

633.6 
190.0 
175.1 

743.8 

Sausage,  bologna 

1.8 
170.7 

6.6 
631.6 

289.3 
859.3 

Bread,  butter,  etc 

i. 

255.2 

998.7 

638.2 

1,892.4 

1 

' 



Our  table  is  intended  to  show  the  food  values,  expressed  in  pro- 
teids,  fats,  and  carbohydrates,  that  are  contained  in  the  different  arti- 
cles of  food  actually  served  out  to  the  men  during  a  week  on  board 
the  U.  S.  S.  Prairie.  The  table,  incidentally,  shows  many  points  of 
considerable  interest  that  are  worthy  of  study;  these  I  need  not  point 
out.  The  cardinal  point  brought  out  in  the  calculation  is  that  the 
average  daily  number  of  nutrient  units  served  in  the  form  of  food, 
per  man,  amounts  to  5953,  just  twice  the  number  required  by  an 
adult  workingman  of  an  average  weight  of  70  kilos.  Hence  our 
examination  has  shown  conclusively  that  the  new  ration,  as  handled 
on  board  the  U.  S.  S.  Prairie,  is  overwhelmingly  in  favor  of  the 
quantitative  sufficiency  of  the  same. 

As  regards  the  relative  proportions  existing  between  proteids, 
fats,  and  carbohydrates,  we  have  seen  that  they  must  accord  with  cer- 
tain percentage  requirements.  A  properly  constructed  ration  must 
contain,  according  to  the  accepted  standard,  20  per  cent,  in  proteids, 
13V,o  per  cent,  in  fats,  and  Q7'/,o  per  cent,  in  carbohydrates.  The 
following  "table  of  percentages"  is  intended  to  exhibit  the  results  of 
an  examination  of  onr  ration  in  this  respect: — 


J32 


TEXT-BOOK  OF  HYGIENE. 
Table  LI. 

Table  of  Percentages. 


In  per  cent. 

Differences 

Days  of  the  Week 

Proteids 

Fats 

Carbo- 
hydrates 

53.6 
46.8 
48.0 
51.6 
50.9 
44  6 
40.4 

Proteids 

Fats 

Carbo- 
hydrates 

Sunday  

14.8 
11.4 
13.0 
12.6 
11.3 
24.6 
19.6 

31.6 

41.8 
39.0 
35.8 
37.8 
30.8 
40.0 

-5.2 
-8.6 
-7.0 
-7  4 
-8.8 
+4.6 
-  .4 

+18.3 
+28.5 
+25  7 
+22  5 
+24.5 
+  17.5 
+26.7 

—13  1 

Monday 

-20  9 

Tuesday 

—19  7 

Wednesday 

Thursday 

-15.1 

-15  8 

Friday 

—22  1 

Saturday 

—26  3 

Average 

15.3 

36.7 

48.3 

-4.7 

+23.4 

-18.4 

In  this  table  the  various  sums  of  the  nutrient  units  in  proteids, 
fats,  and  carbohydrates  for  the  three  daily  meals  expressed  in  per- 
centages, occupy  the  first  three  columns  and  the  plus  and  minus 
deviations  from  the  required  normal  standard  the  last  three  columns. 
The  table  shows  that  the  fats  are  in  excess  of  the  standard,  while  both 
the  proteids  and  carbohydrates  show  marked  deficiencies. 

The  conclusion  reached  after  an  examination  of  the  diet  table 
given  above  is  that,  from  the  point  of  view  of  sufficiency,  the  ration 
exceeds  the  requirements,  but  apart  from  this  shows  certain  limi- 
tations. 

WATER-SUPPLY. 

Although  all  naval  vessels  and  nearly  all  the  larger  vessels  of 
the  mercantile  marine  are  at  present  supplied  with  distillers  for  the 
production  of  drinking-water  from  sea-water,  they  cannot  be  said  to 
be  entirely  independent  of  the  water-supplies  from  natural  sources 
on  shore.  Circumstances  arise  on  every  vessel,  and  often  at  that, 
under  which  the  water-tanks  are  filled  with  water  from  shore,  and 
naval  sanitarians,  therefore,  cannot  yet  afford  to  disregard  the  general 
hygiene  of  water-supplies  from  all  sources.  Since,  however,  this  sub- 
ject is  treated  of  in  another  part  of  this  work,  the  supply  of  drinking- 
water  from  sea-water,  as  usually  done  on  board  ships,  will  alone  be 
spoken  of  in  this  connection. 

On  board  all  of  the  vessels  of  the  United  States  Navy  the  so- 
called  United  States  Standard  Evaporator  is  used  (see  Fig.  35). 
This  evaporator  is  made  of  several  sizes,  the  largest  of  which  pos- 
sesses a  productive  capacity  of  10,000  gallons  of  distilled  water  per 
diem.     The  general  design  is  identical  for  all  sizes.     The  apparatus 


WATER-SUPPLY. 


333 


-Distilling  Plant  as  Installed,  in  Vessels  of  the  United 
States  Navy. 


consists  of  two  parts,  namely:  (1)  the  evaporator,  and  (2)  the  dis- 
tiller, sometimes  called  the  condenser.  The  evaporator  consists  of  a 
hollow,  cylindrical  shell,  made  of  steel  and  placed  horizontally.  The 
lower  half  of  this  cylinder  is  occupied  by  tubes  running  lengthwise 
and  fixed  in  their  positions  at  either  end  to  a  pair  of  plates  which 


334  TEXT-BOOK  OF  HYGIENE. 

permit  of  the  tubes  being  removed  for  sealing  in  tlieir  entirety.  The 
tubes  are  connected  with  the  main  boilers,  from  which  steam  is  run 
into  them,  generally  at  a  pressure  not  exceeding  forty  pounds.  The 
sea-water  intended  for  distillation  fills  that  portion  of  the  lower  half 
of  the  cylinder  which  is  outside  the  tubes,  but  not  quite  reaching  the 
upper  level  of  the  highest  tubes.  It  is,  indeed,  the  intention  that  the 
tubes  shall  not  be  entirely  immersed  in  the  salt-water,  the  upper  level 
of  which  is,  on  the  contrary,  maintained  on  a  level  considerably  below 
that  of  the  tubes.  The  customary  pressure  within  the  shell  is  about 
ten  pounds.  By  the  use  of  the  valves,  the  density  of  the  sea-water  is 
generally  maintained  at  V32.  The  tubes  of  the  distiller  are  made  of 
tinned  copper  or  brass;  the  joints  are  soldered. 

Thus  we  see  that  the  evaporation  of  the  sea-water  is  caused  by  the 
heat  imparted  to  it  through  the  steam  in  the  pipes  which  the  sea- 
water  surrounds.    The  steam  itself  does  not  mix  with  the  sea-water. 

The  distiller  or  condenser  is  a  cylinder,  made  of  brass  or  iron 
in  various  sizes,  placed  vertically  and  fitted  with  straight  tubes  for 
circulating  cooling  water,  which  is  made  to  enter  at  the  bottom  and 
discharge  at  the  top.  The  steam  to  be  condensed  passes  through  the 
distiller  in  the  inverse  sense. 

On  vessels  which  are  equipped  with  very  large  plants  for  dis- 
tilling water,  the  apparatus  is  arranged  somewhat  differently  from  the 
above.  The  work  of  distilling  is  divided  into  two  or  three  stages, 
and  thus  the  working  efficiency  of  the  plant  is  thereby  correspondingly 
increased.  Under  this  system,  steam  from  the  boilers  is  used  to 
evaporate  the  water  in  the  first  set  of  evaporators ;  this  evaporated 
steam  is  used  to  heat  and  evaporate  the  water  contained  in  the  sec- 
ond set  of  evaporators;  and  this  in  turn,  is  made  to  evaporate  the 
water  contained  in  a  third  set.  The  steam  from  the  last  is  finally 
condensed  to  water  in  a  distiller  of  the  above  description.  This  sys- 
tem more  than  doubles  the  actual  thermal  efficiency  of  the  apparatus, 
but  it  is  not  installed  except  in  very  large  ships,  on  account  of  the 
complications  in  mechanical  fittings  which  it  necessitates. 

The  precautions  usually  observed  are  as  follows :  ( 1 )  The  plant 
should  be  used  only  when  pure  sea-water  is  available.  (3)  For 
drinking-water,  the  apparatus  should  not  be  used  to  its  full  capacity, 
in  order  to  reduce  priming  or  carrying  of  salt-water  directly  over 
into  the  distillate.  (3)  Tests  of  the  complete  plant  to  be  made  daily 
to  insure  tightness  of  all  the  joints.  (4)  The  water  level  in  the 
evaporators  is  to  be  kept  low.  (5)  When  the  ship  is  under  way  and 
rolling  heavily,  the  plant  must  be  worked  at  its  lowest  capacity.     (6) 


WATER-SUPPLY. 


335 


The  pressure  of  the  cooling  water  in  the  distiller  is  limited  by  de- 
partmental order  to  thirty  pounds,  which  is  to  minimize  the  danger  of 
salt-water  leaking  into  the  distiller.  (7)  Tests  of  the  distillate  are 
to  be  made  every  fifteen  minutes. 

That  the  water  produced  by  this  evaporator  is  liable  to  contain 
certain  substances  not  expected  to  be  present  in  chemically  pure  dis- 
tilled water  may  be  seen  from  the  adjoining  table,  which  exhibits  the 
results  of  twenty-two  analyses  of  the  water  it  produces,  made  on  the 
U.  S.  S.  Prairie. 

Table  LII. 

Tabulated  Besults  of  Twenty-two  Analyses  of  Water  Distilled  from  Salt 
Water  by  the  United  States  Standard  Evaporator. 


U.  S.  S.  Prairie,  Gulf  of  Paria, 
January,  1902 

.2 
'S 

o 

a 

a 
< 

1 

1 

oT  1  01 

.sis 

'a 
"  a  ° 

Organic  Matter, 

Represented  in 

Milligrams  of 

Oxygen  per  Litre 

3 

+ 

0 

+ 
+  + 

+ 
+  + 

+ 

0 

+ 

+ 

+ 

+ 
+  + 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

9 

0 
+  + 

0 

0 

0 
+  + 

0 

0 

0 

0 

0 

0 

0 

0 
0 
0 
0 
0 
0 
0 
0 
+ 

0 
0 
0 
0 
0 
0 
0 
0 
0 

220 
30 
20 
10 
50 
20 
24 

130 

8 

12 

20 

20 

160 
30 
30 
20 
90 
12 
20 
32 
80 
32 

10.0 
5.0 
40 
6.0 

11.0 

16.0 
70 

13.0 
4.0 
4.0 
5.5 
6.0 

10.0 
4.5 
5.0 
5.0 

10.0 
70 
8.0 
6.0 
80 
5.0 

0.0 

4 

2.0 

5 

3.5 

6 

1.7 

7 

3.6 

8 

2.0 

9 

3.2 

10 

6.5 

13 

2.0 

14 

30 

16 

3.0 

17 

3.0 

18 

4.0 

20 

4.5 

21 

5.0 

22 

30 

23 

2.5 

25 

2.0 

26 

30 

27 

2.0 

28 

120.0 

30 

3.0 

These  impurities  are  occasioned  by  defects  in  the  water-making 
plant.  The  defects  consist  in  slight  leaks  in  the  coils  of  the  patent 
evaporator,  which  contain  about  forty-eight  conical  steam-joints,  which 
are  apt  to  work  loose  after  long  and  hard  usage.  It  may  be  readily 
seen  that  any  leak  of  boiler  steam  through  any  of  these  joints  must 
carry  into  the  distiller  whatever  impurities  it  contains,  such  as  salts 
of  all  kinds,  rust,  or  grease. 


336  TEXT-BOOK  OF  HYGIENE. 

The  defect  can  be  remedied  by  filling  the  coils  of  the  patent 
evaporators  with  steam  from  the  low-pressure  side  of  the  larger  third 
evaporator.  The  effect  of  this  change  is  to  make  the  evaporating  plant 
one  of  "double  effect."  The  steam  from  the  boilers  enters  the  large 
evaporator-coils  and  evaporates  salt-water.  The  steam  from  this  evap- 
orator, before  going  to  the  distiller,  is  condensed  in  the  coils  of  the 
two  smaller  evaporators,  and  only  passes  through  the  distiller  to  be 
cooled.  Of  course,  any  leak  from  the  steam  side  to  the  water  side 
of  the  small  evaporators  involves  a  slight  loss  of  efficiency,  but  such 
a  leak,  no  matter  how  great,  can  no  longer  make  the  distillate  impure. 

Besides  the  impurities  due  to  defects  in  the  central  distilling 
plant,  we  sometimes  find  that  the  drinking-water  is  contaminated 
from  other  sources.  While  the  water  taken  from  the  distiller  proves 
to  be  pure,  an  analysis  of  the  water  taken  from  any  spigot  may  show 
that  it  is  not  safe  to  drink.  Such  impurities  can  be  due  only  to 
dirty  water-tanks  or  to  faulty  pipe  connections.  Thus,  for  instance, 
it  will  sometimes  happen  that  one  of  the  tanks  is  used  for  other  pur- 
poses than  the  storage  of  the  purest  drinking-water  and,  before  it 
was  cleaned,  drinking-water  from  the  distiller  is  again  run  into  it. 
Iron  pipes  may  cause  the  water  to  be  contaminated  with  iron  rust, 
and  lead  pipes  may  contaminate  it  with  small  amounts  of  lead.  All 
this  goes  to  show  how  necessary  it  is  that  the  water  on  board  ship 
must  be  analyzed  occasionally,  and  that  the  mere  fact  that  the  water 
is  distilled  must  not  be  allowed  to  throw  the  sanitarian  off  his  guard. 

With  regard  to  the  daily  allowance  of  water  per  man,  there  are 
no  hard-and-fast  rules  in  the  navy  according  to  which  this  is  regu- 
lated. The  natural  consequence  of  this  is,  as  might  be  expected,  that 
the  supply  varies  directly  on  board  the  different  vessels  with  the 
individual  caprice  or  the  understanding  of  the  officer  in  command, 
being  dealt  out  liberally  on  some  and  parsimoniously  on  others. 
While  there  is,  generally,  enough  drinking  water  allowed,  there  is  in 
all  the  ships  too  much  economy  shown  in  the  supply  of  the  men  with 
sweet  water  for  purposes  of  bathing  and  washing  clothes. 

The  result  of  this  false  economy  is,  first,  that  the  men  cannot 
keep  their  skins  as  clean  as  they  ought  to;  and,  second,  for  washing 
their  clothes,  the  men  with  the  cleanest  habits  and  instincts  will 
often  get  sweet  water  from  forbidden  sources  and  store  it  away  in 
buckets  which  they  hide  in  all  conceivable  places  for  future  use,  until 
they  are  discovered  by  the  inspecting  officer,  when,  of  course,  they 
not  only  lose  the  water,  but  are  reported  and  punished  for  the  mis- 
demeanor.   When  it  is  considered,  from  a  sanitary  point  of  view,  that 


WATER-SUPPLY.  337 

it  is  economy  to  be  lavish  with  the  water  supply,  and  that  especially 
sailors  should  be  so  trained  that  cleanliness  of  person  must  become 
for  them  a  habit,  it  will  at  once  be  seen  how  pernicious  this  prac- 
tice is. 

The  great  necessity  for  a  proper  care  of  the  skin  becomes  espe- 
cially apparent  in  the  tropics,  where,  owing  to  the  increased  activity 
of  the  sweat-glands,  skin  eruptions  and  cutaneous  abscesses  are  of  the 
most  frequent  occurrence.  Such  troubles  not  only  greatly  add  to 
the  discomfort  of  the  men,  but  are  the  efficient  causes  for  numerous 
and  frequent  admissions  to  the  sick-list,  resulting  in  a  loss  to  the 
service  of  a  great  many  working  days.  That  better  facilities  for 
bathing,  for  both  officers  and  men,  should  be  provided  on  board  all 
the  ships  of  the  navy  than  are  at  present  available  is  a  fact  upon  which 
all  officers  agree.  It  is  the  duty  of  the  sanitarian  to  do  all  in  his 
power  and  urge  this  necessity  upon  the  constructors  of  new  vessels 
whenever  he  can. 

Since  it  is,  of  course,  out  of  the  question  that  a  sufficient  number 
of  bath-tubs  be  provided  for  a  large  ship's  company,  shower-baths 
can  alone  be  considered  for  the  men.  In  some  of  the  larger  war 
vessels  of  the  German  navy  places  for  showers  have  been  provided 
in  which  fifteen  men  may  receive  a  douche  at  one  time,  so  that,  accord- 
ing to  the  calculations  of  Nocht,  300  men  may  be  served  in  two  hours' 
time,  at  an  average  expenditure  of  1200  gallons  of  water.  Since, 
besides  this,  1%  gallons  is  the  minimum  allowance  of  water  per  man 
and  per  day  for  purposes  other  than  drinking,  we  have  here  a  basis  for 
calculating  the  total  water-supply  needed  for  twenty-four  hours  and  for 
the  capacity  of  the  distillers  that  are  required  to  furnish  the  same. 

The  first  receiving  ship  in  the  United  States  navy  on  which  the 
wash-rooms  and  bath-rooms  for  the  men  have  received  the  attention 
at  all  commensurate  with  their  importance  is  the  recently  converted 
ship  Lancaster  at  the  Navy  Yard,  League  Island,  Pennsylvania. 
This  ship  provides  accommodations  for  730  men.  The  wash-room  is 
on  the  forward  part  of  the  spar  deck,  having  a  cubic  capacity  of  3584 
feet,  and  contains  12  reversible  wash-basins,  all  supplied  with  hot  and 
cold  water.  The  bath-room  has  a  cubic  capacity  of  2040  feet  and 
contains  8  showers,  supplied  with  hot  and  cold  water,  the  temperature 
of  which  may  be  regulated.  This  very  excellent  arrangement  calls  for 
the  widest  possible  general  application  on  all  sea-going  vessels  of 
the  navy. 

Before  leaving  the  subject  of  the  water-supply,  a  few  words  must 
be  added  on  the  scuttlc-1)utt  question.     The   sc-uttle-butt,   so-called, 

22 


338  Text-book  of  hygiene. 

is  an  iron  tank  filled  with  water  and  provided  with  one  or  more 
spigots  near  the  bottom  of  it,  from  which  the  men  take  their  drinking- 
water  by  means  of  a  cup.  This  cup  is  suspected  of  being  the  means 
of  the  spread  of  infectious  disease  on  shipboard,  especially  during  the 
prevalence  of  epidemics  like  diphtheria,  mumps,  etc.  Numerous 
recommendations  have  been  made  to  eliminate  this  danger,  one  of 
the  most  recent  ones  being  that  of  Dr.  C.  F.  Stokes,  U.S.N.,  who  sug- 
gested that  the  cup  be  immersed  in  a  solution  of  formaldehyde  of 
1 :  2500  while  not  in  use.  While  this  practice  would  undoubtedly 
diminish  the  chances  of  transmission  of  infection,  it  could  not  be 
said  that  it  would  altogether  prevent  it. 

When  we  consider  that  the  feeling  of  thirst  generally  manifests 
itself  in  a  number  of  men  at  the  same  time,  and  that  often  from 
twenty  to  thirty  men  may  be  observed  standing  in  a  line  and  wait- 
ing their  chances  to  use  the  same  cup,  the  paraldehyde  solution  would 
not  get  a  chance  to  act  on  any  infectious  material  left  on  the  cup 
by  a  previous  drinker  before  the  next  one  came  along.  The  only 
possible  way  of  preventing  the  transmission  of  infection  by  means  of 
the  cup  is  to  do  away  with  the  cup  altogether,  and  serve  water  through 
a  fountain  so  constructed  that  a  small  stream  of  water  may  be 
directed  into  the  back  part  of  the  mouth  without  the  drinker  having 
a  chance  to  touch  the  little  spout  with  his  lips.  This  might  easily 
be  effected  by  converting  the  scuttle-butt  into  a  cylinder  provided  at 
intervals  on  its  circumference  with  several  cup-shaped  depressions, 
from  the  bottom  of  each  of  which  a  small  stream  of  water  is  forced  out 
by  gravity  and  which  could  be  regulated,  by  a  sort  of  spring-lock. 
While  the  rim  of  the  depression  might  touch  the  face  of  the  drinker, 
the  cup-shaped  depression  ought  to  be  made  deep  enough  so  that  the 
lips  could  not  touch  the  nipple  of  the  spout.  In  order  to  catch  the 
small  amount  of  water  that  is  spilt  in  the  operation,  a  circular  trough 
connected  with  a  soil-pipe  could  be  placed  below  the  fountain. 

VENTILATION. 

Ventilation  may  be  either  natural  or  artificial.  In  nature,  wind- 
currents  are  created  by  temperature  differences.  High  temperatures 
over  any  point  on  the  earth's  surface  cause  the  atmosphere  to  expand 
and,  consequently,  to  rise;  low  temperatures  have  the  opposite  effect. 
A  current  is  caused,  therefore,  proceeding  from  centres  of  lotv  towards 
centres  of  high  temperatures.  We  speak  of  ventilation  as  being 
natural,  whenever  air-currents  are  created  by  atmospheric  tempera- 
ture differences  alone;    ventilation  becomes  artificial  whenever  these 


VENTILATION.  339 

natural  currents  are  assisted  by  other  physical  or  mechanical  agencies. 
The  ventilation  which  is  constantly  taking  place  in  our  houses 
and  dwellings  may  be  taken  as  an  example  of  natural  ventilation. 
The  porous  nature  of  the  building  materials,  the  winds,  the  differences 
between  the  temperatures  of  the  inside  and  outside  air,  are  the  effi- 
cient causes  of  this  ventilation.  In  an  experiment  by  von  Petten- 
kofer  it  was  found  that  in  a  room  of  75  cubic  metres  capacity,  one 
complete  change  of  air  occurred  in  one  hour  through  a  difference  in 
temperature  between  inside  and  outside  of  20°  C.  Under  ordinary 
conditions,  the  cold  air  will  enter  below  and  the  warmer  air  will 
make  its  escape  from  the  top  of  the  building. 

Such  natural  ventilation,  it  will  readily  be  seen,  could  never  be 
expected  to  occur  in  a  ship.  A  ship's  bottom  and  sides  are  practically 
made  both  air-  and  water-  tight.  Hence,  whatever  fresh  air  is  ex- 
pected to  get  into  a  vessel  must  come  from  the  top  side  and  be  made 
to  find  its  way  to  all  the  various  parts  below  before  it  can  be  said  that 
the  ship  is  at  all  ventilated.  Since,  moreover,  a  ship  is  divided  into 
many  separate  compartments  not  in  direct  communication  with  the 
general  ship's  spaces,  the  air  (the  deeper  it  descends  the  warmer  it 
must  get)  will  be  returned  before  it  reaches  the  deepest  parts  of  the 
ship;  it  thus  must  happen  that  a  large  portion  of  the  inside  of  a 
ship  will  never  be  ventilated  by  natural  means  at  all.  This  is  also 
the  reason  why  the  air  in  ships  is  always  found  to  be  growing  more 
and  more  contaminated,  the  deeper  down  towards  the  bottom  it  is 
examined.  We  may  now  also  understand  why  it  is  that,  in  order  to 
ventilate  all  ships  effectively,  we  must  resort  to  ventilation  by  arti- 
ficial means. 

Since  the  most  economical,  thorough,  and  efficient  ventilation  is 
that  ventilation  which  aids  the  natural  currents  existing  inside  of  a 
vessel,  all  artificial  systems  should  be  so  arranged  as  to  meet  this 
most  important  requirement.  In  a  steamer,  for  instance,  of  modern 
construction,  such  as  a  cruiser  or  battleship,  with  enormous  fires  and 
engine-rooms,  large  steam-pipes,  and  a  number  of  auxiliary  engines 
situated,  for  the  most  part,  in  the  middle  of  the  ship's  space  and 
radiating  considerable  amounts  of  heat,  air-currents  from  all  parts  of 
a  vessel  would,  under  average  conditions,  move  in  their  direction; 
that  is,  from  the  colder,  loioer,  and  peripheral  portions  toward  the 
warmer,  higher,  and  central  parts  of  the  compartments.  All  supply 
shafts  in  a  ship,  in  accordance  with  this  principle,  should,  therefore, 
be  made  to  reach  as  nearly  as  possible  the  bottom  and  the  most  periph- 
eral parts  of  any  compartment  to  be  ventilated,  before  being  allowed 


340  TEXT-BOOK  OF  HYGIENE. 

to  set  free  the  imprisoned  air  which  they  brought  down  from  above 
and  which  is  intended  for  the  ventilation  of  any  particular  compart- 
ment; while  the  outlets  for  the  foul  air  should,  for  the  same  reasons, 
be  nearest  the  middle  line  and  open  flush  with  the  deck  ceiling.  It 
is  in  this  manner  only  that  any  compartment  can  be  most  efficiently, 
as  well  as  most  economically,  ventilated. 

Different  Methods  of  Ventilation. — A  ship  is  said  to  be  ventilated 
either  by  the  vacuum  or  the  plenum  method,  according  as  the  greater 
motive  power  is  in  the  discharge  or  in  the  supply  part  of  the  system. 
The  power  may  be  solely  in  either  one  or  the  other  of  the  two  parts, 
or  it  may  be  shared  between  them.  Its  predominance  in  the  one  or 
the  other  determines  the  "^vacuum"  or  the  "plenum"  character  of 
the  system.     (Woodbridge.) 

Vacuum  Method. — This  method  causes  a  current  of  air  in  an 
enclosure  by  a  partial  vacuum  within  it.  Into  such  an  enclosure  the 
air  then  flows  through  every  available  channel,  both  provided  and  ac- 
cidental. From  whatever  points,  therefore,  the  pressure  may  be 
greater  than  in  the  enclosure  ventilated  by  the  vacuum  method,  from 
thence  it  will  move  toward  that  enclosure.  Each  space,  therefore,  is 
more  or  less  at  the  mercy  of  its  surroundings  and  of  conditions  be- 
yond the  control  of  its  occupants.  The  vacuum  method  of  ventila- 
tion on  shipboard  puts  the  breather  at  the  point  of  discharge  of  foul 
air,  and  sends  into  the  living  spaces  specimens  of  air  from  every  part, 
near  or  remote,  whether  filled  with  pure  or  foul  air. 

Plenum  Method. — This  method,  by  putting  each  compartment 
under  slight  pressure,  prevents  leakage  of  air  from  adjoining  com- 
partments. It  tends  to  accelerate  the  escape  of  foul  air  through 
natural  outlets,  and  gives  the  occupants  control  over  the  source  and 
the  velocity  of  their  air-supply.  The  method  puts  the  breather  at 
the  point  of  supply  and,  consequently,  in  a  position  to  breathe  the 
best  of  air.  It  is  recommended  as  the  best  by  Eubner,  Kirchner,  Karl 
Schmidt,  Notter,  Harrington,  Woodbridge,  and  Munson.  It  will 
supply  a  steady  current  of  fresh  air  to  all  the  compartments  in  a 
ship  alike,  and  by  tending  to  produce  even  conditions  of  temperature 
and  pressure  it  will  prevent  untoward  currents  and  countercurrents 
between  the  different  enclosures,  in  spite  of  free  communication  exist- 
ing between  them. 

The  ideal  aim  of  any  ventilating  system,  in  theory  at  least,  would 
be  the  getting  rid  of  foul  air  in  an  enclosure  and  the  replacing  of 
this  by  fresh  air,  without  the  two  becoming  mixed.  In  practice, 
however,  and  as  Rubner  has  long  since  pointed  out,  we  are  obliged 


VENTILATION.  34  j^ 

to  take  our  air  for  inspiration  out  of  the  same  reservoir  into  which 
we  send  our  expiratory  air.  It  would,  therefore,  seem  impossible 
for  any  ventilating  system  to  so  sharply  separate  the  good  air  from 
the  foul  air  as  to  prevent  the  two  from  becoming  mixed  to  a  certain 
extent.  All  artificial  ventilation  must,  accordingly,  proceed  after  the 
manner  of  a  process  of  dilution,  and  be  so  arranged  as  to  keep  the 
enclosed  air  from  reaching  a  composition  very  much  different  from 
outside  air.  This  is  more  especially  the  case  on  board  all  ships,  naval 
as  well  as  mercantile,  under  just  such  conditions  when  ventilation 
comes  into  play  most  beneficiently,  namely,  during  maneuvres  and  in 
bad  weather.  It  is,  consequently,  far  more  important  to  provide  means 
for  an  abundant  supply  of  fresh  air  in  the  ventilating  of  sliips  than 
it  is  to  provide  those  for  getting  rid  of  foul  air.  The  more  general 
introduction  of  the  plenum  system  in  ships'  ventilation  is,  therefore, 
most  desirable,  as  well  as  in  the  most  perfect  keeping  with  the  re- 
quirements. 

Since  the  details  of  ship  ventilation  and  the  principles  of  the 
examination  of  air,  as  well  as  the  sources  of  its  contamination,  have 
been  very  recently  discussed  by  Beyer  and  Plumert,  we  may  conclude 
this  chapter  by  giving  a  description  of  the  type  plans  for  the  ventila- 
tion of  some  of  our  newest  designs  of  battleships. 

But  before  giving  this  description,  mention  must  be  made  of  an 
important  discovery  as  regards  the  composition  of  the  air  enclosed  in 
the  double  bottoms,  by  Dr.  C.  M.  Belli.  It  had  been  known  for  a 
long  time  that  the  air  in  these  places  became  after  a  time  so  bad  that 
it  was  dangerous  to  enter  them,  without  testing  the  air  first  by  means 
of  a  candle,  and  whenever  that  went  out  the  air  in  them  was  renewed 
with  a  portable  ventilator.  It  was  always  believed  that  the  cause  of 
the  asphyxia  was  an  accumulation  of  CO2  in  these  places. 

Belli,  on  the  contrary,  found,  by  a  number  of  eudiometric  analyses 
of  specimens  of  air  collected  from  these  double  bottoms,  that  while 
the  CO2  was  present  in  the  proportion  of  1.4  per  cent.,  the  oxygen 
had  decreased  from  20  to  3  per  cent.  Hence  it  would  seem  that  all 
previous  cases  of  asphyxia  reported  as  occurring  in  the  double  bot- 
toms were  due  to  a  want  of  oxygen  rather  than  to  the  presence  of  too 
much  COo.  Further  experiments  showed  that  the  oxygen  was  indeed 
absorbed  by  the  linseed  oil  and  minium,  a  mixture  with  which  the 
iron  sides  and  bottoms  of  these  compartments  are  thickly  coated.  It 
would  not  be  surprising  if  it  should  be  found,  on  further  experi- 
mentation, that  a  want  of  oxygen  more  than  the  accumulation  of  CO2 
was,  after  all,  the  real  cause  of  the  insufferable  condition   of  the 


342  TEXT-BOOK  OF  HYGIENE. 

atmosphere  of  places  in  ships  other  than  the  double  bottoms.  Ex- 
perimental inquiries  alone  can  establish  the  truth  of  this  supposition. 

The  Ventilating  System  of  the  Idaho  and  Mississippi. — The 
Idaho  and  Mississippi  are  sister  ships  and  classified  as  first-class  sea- 
going and  coast-line  battleships.  Their  length  and  breadth,  at  load 
water-line,  are  375  and  77  feet  respectively.  The  displacement  is 
13,000  tons.  They  have  a  bridge  deck,  upper  deck,  main  deck,  berth 
or  protective  deck,  and  an  upper  and  lower  platform.  They  will  each 
carry  a  complement  of  not  less  than  720  officers  and  men. 

According  to  the  designs  of  these  vessels,  it  is  the  intention  to 
provide  artificial  ventilation  for  all  quarters,  living  spaces,  passages, 
store-rooms,  and  magazines  below  the  main  deck,  as  well  as  for  the 
air-spaces  over  the  boiler-  and  engine-  rooms  and  around  magazines; 
for  the  water-closets  and  similar  enclosures  above  the  main  deck  and 
for  turrets.  The  hull-ventilating  arrangements  for  these  vessels  were 
designed  in  accordance  with  what  are  considered  the  latest  approved 
methods,  the  efficiency  of  which  was  demonstrated  by  numerous  ex- 
periments. The  system  has  been  so  subdivided  as  to  render  unneces- 
sary the  piercing  of  any  of  the  principal  water-tight  bulkheads  with 
the  ducts  except  M^here  shown  in  the  type  plans  (Figs.  36,  37,  and  38). 

These  vessels,  having  a  system  of  hatches  and  skylights  opening 
through  the  various  decks  in  nearly  vertical  lines,  in  a  number  of  the 
principal  subdivisions,  it  was  not  considered  necessary  to  install  both 
"supply"  and  "exhaust"  systems  for  any  spaces  except  the  dynamo- 
rooms.  The  main  hull  ventilation  will  therefore,  be  fitted  as  shown 
in  the  type  plans  (see  Figs.  36,  37,  and  38)  with  the  single-way  sj^s- 
tem.  The  water-closets,  etc.,  on  the  main  deck  will  be  ventilated  on 
the  "exhaust"  system  and  the  remaining  compartments,  except  the 
dynamo-rooms,  on  the  "supply"  or  "plenum"  system  only. 

The  ducts  are  designed  to  pass  the  number  of  cubic  feet  of  air 
per  minute  through  each  terminal  as  may  be  seen  on  the  type  plans 
(see  Figs.  36,  37,  and  38),  or  to  equal  the  total  number  of  cubic 
feet  per  minute  for  each  compartment  as  marked  on  the  plans,  with 
the  fans  running  at  a  speed  corresponding  to  1  ounce  pressure  with 
restricted  delivery.  This  will  allow  the  air  to  be  renewed  in  the  vari- 
ous spaces  approximately  as  follows : — 

1.  Officers'  quarters  and  crew  space,  berth  deck  outside  of  trans- 
verse armor,  in  about  twelve  minutes,  or  four  times  in  one  hour. 

2.  Officers'  quarters,  crew  space,  and  general  work-shop,  within 
transverse  armor,  in  about  five  minutes,  or  twelve  times  in  an  hour. 

3.  Water-closets  and  crew's  head  in  about  five  minutes. 


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VENTILATION. 


843 


4.  Store-rooms  in  general,  magazines,  and  passages  in  about 
eight  minutes. 

5.  Engine-rooms  and  steering  compartments  in  about  two 
minutes. 

6.  Evaporator-rooms  in  about  two  and  a  half  minutes. 

7.  Air-space  over  boilers  in  about  one  minute. 

8.  Dynamo-rooms  in  about  three-quarters  of  a  minute. 
Twenty-three  fans  are  required  for  the  ventilating  system  of  these 

vessels,  all  to  be  electrically  driven  and  to  be  located  as  indicated  on 
the  plans   (see  Figs.  36,  37,  and  38). 

Pan  No.  1.— To  exhaust  from  water-closets,  etc.,  on  the  main 
deck  forward  of  bulkhead  No.  15,  and  also  from  sick-bay  water- 
closet  and  contagious  ward. 

Fans  Nos.  2  and  3.— To  exhaust  from  firemen's  wash-rooms, 
evaporator-rooms,  and  passages  on  berth  deck,  between  bulkheads' 
351/2  and  57.  The  discharges  from  these  fans  to  be  used  for  ventilat- 
ing the  air-spaces  over  boilers. 

Fan  No.  4.— To  exhaust  from  officers'  water-closets  on  main  deck 
between  bulkheads  521/2  and  59.  The  discharge  to  be  used  to  assist 
exhaust  from  after  dynamo-room. 

Fans  Nos.  5  and  6.— To  supply  fresh  air  to  officers'  quarters  and 
to  compartments  above  protective  deck  abaft  bulkhead  57. 

Fans  Nos.  7  and  8.— To  supply  fresh  air  to  magazines  and  store- 
rooms below  protective  deck,  between  bulkheads  Nos.  671/2  and  79,  and 
also  to  ammunition  passages  aft  of  frame  48. 

Fan  No.  9.— To  supply  fresh  air  to  sick-bay,  operating  room, 
dispensary,  store-rooms,  and  passages  above  protective  deck  and  for- 
ward of  bulkhead  No.  19 ;  and  also  to  all  compartments  below  pro- 
tective deck  and  forward  of  bulkhead  No.  19,  except  chain  lockers 
and  trimming  tanks. 

Fans  Nos.  10  and  11.— To  supply  fresh  air  to  magazine  and 
store-rooms  below  protective  deck,  between  bulkheads  Nos.  19  and  30. 

Fans  Nos.  12  and  13.— To  supply  fresh  air  to  compartments  on 
berth  deck  between  bulkheads  Nos.  19  and  351/2  and  to  ammunition 
passages  between  frames  30  and  48 ;  also  to  communication  room,  and 
forward  distribution  board-room. 

Fans  Nos.  14  and  15.— To  supply  fresh  air  to  forward  dynamo- 
room. 

Fans  Nos.  16  and  17.— To  exiiaust  from  compartment  between 
bulkheads  Nos.  30  and  35%  on  berth  deck,  the  discharge  to  be  used 
to  assist  exhaust  from  the  forward  dynamo-room. 


344  TEXT-BOOK  OF  HYGIENE. 

Fans  ISTos.  18  and  19. — To  supply  fresh  air  to  after  dynamo-room 
and  after  distribution  board-room. 

Fans  No.  20  and  21. — To  supply  fresh  air  to  engine-rooms. 

Fans  Nos.  22  and  23. — To  supply  fresh  air  to  steering  com- 
partments and  store-rooms  on  upper  platform  aft  of  bulkhead  No. 
79;   also  to  hold  between  bulkheads  Nos.  79  and  83. 

It  is  the  intention  to  supply  all  these  fans  with  power  sufficient 
to  run  them  continuously,  when  necessary,  at  a  speed  required  to 
produce  IV2  ounces  pressure,  under  conditions  of  shop  test,  but  to 
have  such  variation  in  speed  as  will  permit  them  to  run  under  or- 
dinary service  conditions  at  the  speed  required  to  produce  1  ounce 
pressure. 

In  designing  the  ventilating  system  for  these  ships,  great  care  has 
been  taken  to  allow  for  the  loss  of  capacity  due  to  frictional  resist- 
ance, and  special  attention  was  paid  to  the  bends  in  the  ducts,  none 
of  which  are  to  be  made  with  a  radius  of  throat  smaller  than  the 
diameter  of  the  duct.  It  was  found  by  experiment  that  the  loss  due 
to  friction  in  a  twent3'-foot  length  of  straight  duct  is  about  10  per 
cent.,  and  that  the  loss  in  a  ninety-degree  bend,  when  proj)erly  con- 
structed, with  a  radius  of  throat  not  less  than  the  diameter  of  the 
duct,  is  about  the  same  amount.  If  the  bends  are  made  with  a  sharp 
joint  or  with  a  smaller  radius,  the  loss  will  be  greater.  The  ducts 
are  to  be  made  smooth  inside  and  free  from  all  internal  projecting  lips 
and  other  obstructions.  The  branches  and  terminals  will  be  m:ide  to 
leave  the  main  duct  at  an  angle  of  not  more  than  15  degrees  to  the 
direction  of  the  air-current  and  be  curved  to  the  desired  direction  by 
a  very  easy  bend.  All  magazine  terminals  will  be  fitted  with  automatic 
ball  attachment  and  cage,  protected  by  portable  one-half  inch  wire 
mesh  covering  the  same.  McCreery  or  other  equally  effective  adjust- 
able elbows,  fitted  with  butterfly  dampers,  will  be  used  for  terminals 
in  all  quarters,  living  spaces,  and  elsewhere,  as  shown  in  type  plans 
(Figs.  36,  37,  and  38).  All  the  openings  of  these  elbows  are  to  be 
fitted  with  portable  wire  mesh,  not  less  than  one-half  inch.  All  other 
terminals  to  be  stationary  and,  except  those  ending  in  valves,  to  be 
fitted  with  plain  butterfly  dampers  and  portable  iron  mesh,  not  less 
than  one-quarter  inch.  All  terminals  to  be  bell-mouthed  to  twice  their 
area,  where  fitted  with  wire  mesh. 


Table  LIII. 

Tabulated  Index  to  Artificial  Ventilation  Arrangevients  of  ^'^  Idaho  ^^  and 
' '  Mississippi, ' '  Shown  in  Part  in  Figs  36,  37,  and  38. 


"3 

FAN 

SPACE 

(^  .2 

s>  Ph  s 

.2  3  a 

a  i  0 

.o     t,    g 

H^S 

3     0).= 
^  V^  < 

Exhaust 

Crew's  head,  over  water-closets 

6 

800 

No.  1  — Main  deck 

'*             "      urinals 

6 

450 

Capacity,  1725  cubic  feet  per 

"             "      wash-basins 

6 

300 

minute 

Contagious  ward 

6 

100 

1  oz.  pressure 

Sick  bay  bath-room 

6 

75 

Exhaust 

Exhaust  from  firemen's  wash-room 

No.  2 — Main  deck 

and  supply  to  air-space  over  boilers 

1 

3070 

Capacity,  3070  cubic  feet 

Exhaust 

Exhaust  from  firemen's  wash-room 

1 

1270 

No.  3 — Main  deck 

"           "       dynamo-room  and 

Capacity,  3070  cubic  feet 

supply  to  air-space  over  boilers 

1 

1800 

Exhaust 

From  officers'  bath  and  water-closet 

4 

943 

No.  4— Upper  deck 

space 

Capacity,  943  cubic  feet 

Supply 

Captain's  after-cabin 

10 

160 

No.  5 — Main  deck 

"        dining-cabin 

10 

200 

Capacity,  4640  cubic  feet 

' '        state-room 
' '         bath-room 

10 
10 

125 

75 

No.  6— 

"         office 

10 

100 

4640  cubic  feet 

"         pantry 

10 

50 

Ward-room  Dining-room 

10 

400 

"          state-rooms  behind 

armor 

4 

100 

"          state-rooms  not  behind 

armor 

10 

75 

' '          pantry 

4 

150 

Junior  and  warrant  officers'  mess- 

rooms  (each) 

4 

400 

Junior  and  warrant-officers'    state- 

Y 

fl25 
1150 

rooms  (each) 

Junior    and  warrant-officers'    pan- 

tries (each) 

4 

125 

Country    in     vicinity    of    officers' 

quarters 

4 

2100 

Supply 

Magazines  on  upper  platform 

8 

2200 

No.  7— 

"         "    lower 

8 

1650 

Capacity,  4640  cubic  feet 

in  hold 

8 

350 

Passages  and  haudling-rooms 

8 

3150 

No.  8— 

Storerooms 

8 

1620 

Capacity,  4640  cubic  feet 

Supply 

Sick  Bay 

n 

600 

No.  9— Berth  deck 

Operating-room 

^ 

125 

Capjicity,  5320  cubic  feet 

Dispensary 

n 

75 

Lamp-room 

8 

125 

Paints  and  oils 

8 

200 

Torpedo  manipulating-room 

8    . 

1600 

Fresh  water  tank  space 

8 

200 

(845) 


Table  LIII. — {Continued.) 

Tabulated  Index  to  Artificial  Ventilation  Arrangemeiits  of  "Idaho''  and 
'  ^Mississippi, ' '  Shoion  in  Part  in  Figs.  36,  37,  and  38. 


FAN 

SPACE 

g  i  a 

Cubic  Feet 
Per  Minute 
About 

Supply 
No.  10— 

Capacity,  3690  cubic  feet 

No.  11— 

Capacity,  3690  cubic  feet 

Magazines  on  upper  platform 
"        on  lower        "' 
in  hold 
Passages  and  handling-room 
Store-rooms 

8 
'  8 
8 
8 
8 

1850 
1720 
1080 
1200 
940 

Supply 
No.  12— Berth  deck 

Capacity,  3070  cubic  feet 

No.  13— 

Capacity,  3070  cubic  feet 

Bakery 

Workshop 

Chief  petty  officers'  quarters 

"          "           "        wash-room 
Crew  space,  berth  deck 
Ice  machine  room 
Ammunition  passages 
Passages 

Communication-room 
Laundry 

8 
5 
5 
5 
5 
5 
8 
8 
8 
5 

150 
330 

500 

90 

400 

100 

2170 

1300 

80 

300 

Supply 
No.  14— Berth  deck 

Capacity,  5320  cubic  feet 

No.  15— 
Capacity,  5320  cubic  feet 

To  forward  dynamo-room 

f 

10,640 

Exhaust 
No.  16— Berth  Deck 
Capacity,  943  cubic  feet 

No.  17— 

Capacity,  943  cubic  feet 

Crew  space 

8 

1886 

Supply 
No.  IS^Berth  deck 
Capacity,  5320  cubic  feet 

No.  19— 

Capacity,  5320  cubic  feet 

To  after  dynamo-room 

i 

10,640 

Supply 
No.  20— 

Capacity,  10,800  cubic  feet 

No.  21— 

Capacity,  10,800  cubic  feet 

To  engine-rooms 

2 

21,600 

Supply 
No.  22— 
Capacity,  1190  cubic  feet 

No   23— 

Capacity,  1190  cubic  feet 

To  steering  gear 
Storerooms 

2 

8 

1615 
765 

Supply 
Two  in  each  boiler  room 
each  15,625  cubic  feet. 

Each  boiler-room 

31,250 

(346) 


QUESTIONS  TO  CHAPTER  XI. 

MARINE  HYGIENE. 

Define  marine  hygiene.  In  what  respects  does  it  differ  from  naval 
hygiene?  What  are  the  causes  of  the  decrease  in  morbidity  and  mortality 
in  modern  ships  as  contrasted  with  those  in  the  old  ships?  What  is  the  mor- 
tality rate  among  seafaring  people  in  recent  times?  Name  some  of  the  most 
prevalent  diseases. 

On  what  system  is  a  ship  drained?  What  are  the  separate  functions  of 
the  main,  secondary  and  auxiliary  drains,  respectively?  How  is  the  bilge 
formed?  Where  is  the  bilge-room  located?  What  changes  in  the  construction 
of  ships  have  affected  the  location  of  the  bilge  space  and  how?  How  is  the 
composition  of  the  bilge  affected  by  these  changes  ?  What  is  a  bilge-well  ? 
What  is  a  Macomb  strainer  and  its  object? 

What  is  the  chemical  and  bacteriological  composition  of  bilge-water? 
How  many  distinct  types  of  bilge-water  may  be  distinguished  on  board  a 
man-of-war?  What  are  the  distinguishing  characters  in  each?  What  are 
the  chances  of  bacterial  infection  from  infected  bilge-waters? 

What  are  the  different  decks  on  a  merchant  ship  called?  Name  the 
different  decks  on  a  battle-ship?  What  is  the  location  of  the  engine-  and  fire- 
room?  What  and  where  are  the  double  bottoms?  Describe  the  location  of 
the  men's  quarters.  What  is  the  usual  cubic  air-space  per  man  allowed,  ( 1 ) 
on  merchant  ships,  and    (2)    on  war-vessels? 

Wliat  is  the  effect  of  dampness  on  shipboard  on  the  health  of  the  men? 
How  is  the  bilge-room  cleaned?  Name  some  of  the  special  precautions  to  be 
observed  in  the  disinfection  of  ships  in  special  cases.  Enumerate  the  most 
necessary  disinfecting  agents  on  board,  and  define  the  uses  of  each.  Describe 
in  detail  the  process  of  Nocht  and  Giemsa  for  the  extermination  of  rats. 

What  is  meant  by  the  term  "ration"  and  what  is  the  difference  between 
it  and  an  ordinary  "bill-of-fare"?  What  are  the  food  values  per  gram  of 
proteids,  fats,  and  carbohydrates  respectively?  What  are  the  relative  pro- 
portions in  proteids,  fats,  and  carbohydrates  to  which  the  composition  of  a 
complete  meal  should  correspond? 

Describe  the  U.  S.  standard  evaporator.  What  may  be  the  sources  of 
contamination  in  the  water  distilled  by  this  machine?  What  are  the  sub- 
stances occasionally  found  in  such  water?  What  is  a  reasonable  allowance 
per  man  and  per  day  on  board  ship?  What  are  the  dangers  of  the  scuttle- 
butt cup  and  how  are  they  to  be  prevented? 

Give  an  example  of  natural  ventilation.  What  is  the  object  of  artificial 
ventilation,  and  how  must  it  be  arranged  to  be  most  effective  as  well  as 
economical?  What  are  the  different  methods  of  artificial  ventilation,  and 
what  does  each  method  do?  WTiich  of  the  two  is  best  adapted  to  ships?  De- 
scribe the  main  features  of  the  ventilating  system  of  the  Idaho  and  Missis- 
sippi. 

(347) 


CHAPTER  XII. 

PRISON  HYQIENE. 

Although  the  frightful  mortality  which  formerly  seemed  a 
necessary  accompaniment  of  the  life  of  the  convict  has  in  the  past 
half-century  markedly  diminished,  the  death-rate  among  prisoners  is 
still  very  greatly  in  excess  of  that  of  persons  of  the  same  age  in,  a  state 
of  liberty. 

The  observations  and  labors  of  John  Howard,  the  self-sacrificing 
philanthropist,  and  of  Elizabeth  Fry,  directed  the  attention  of  legisla- 
tors to  the  necessity  of  reform  in  the  conduct  of  prisons  and  the  treat- 
ment of  prisoners.  As  a  consequence  of  the  labors  of  these  reformers, 
the  principles  of  prison  discipline  have  been  more  fully  developed 
during  the  past  forty  years  by  students  of  social  science  everywhere, 
and  certain  propositions  have  been  formulated,  which  govern,  to  a 
greater  or  less  degree,  legislation  upon  this  subject.  These  propo- 
sitions are,  briefly,  as  follow: — 

Prisoners  must  be  properly  classified  according  to  the  nature 
of  their  crime  and  the  duration  of  imprisonment. 

The  two  sexes  must  be  strictly  separated,  and  no  opportunity 
given  for  intermingling  while  in  the  prison. 

Female  prisoners  should  have  female  attendants  exclusively. 
Male  watchmen  or  other  attendants  should  not  be  allowed  in  the  fe- 
male department  of  a  prison. 

All  prisoners  must  l)e  kept  employed  at  some  manual  labor,  not 
necessarily  for  profit,  but  as  an  agency  in  the  moral  reformation  of 
the  convict. 

Punishments  for  infractions  of  discipline  must  not  be  excessive. 

Efforts  should  be  constantly  made  tending  to  the  reclamation  of 
criminals  from  their  life  of  sin  and  crime. 

Due  care  must  be  taken  by  the  State  to  preserve  the  health  and 
life  of  the  prisoner  whom  the  State  has  deprived  of  liberty  and  the 
opportunity  of  taking  care  of  himself. 

A  proper  classification  of  prisoners,  according  to  the  degree  of 

their  criminality,  the  nature  of  the  crime  of  which  they  have  been 

convicted,  or  the  length  of  time  for  which  they  have  been  sentenced, 

is  now  insisted  upon  by  all  students  of  prison  discipline.    As  this  sub- 

(348) 


PRISON  HYGIENE.  349 

jeet  more  nearly  concerns  the  social  or  legal  relations  of  prisoners 
rather  than  their  sanitary  interests,  it  is  here  passed  over  with  a  mere 
mention. 

The  separation  of  the  sexes,  necessity  of  female  attendants  on 
prisoners  of  the  same  sex,  employment  of  prisoners,  and  moral  re-? 
formation  of  criminals  likewise  belong  especially  to  the  social  aspects 
of  the  question,  and  can  find  no  discussion  in  this  place. 

Eegarding  the  remaining  proposition,  however,  that  which  de- 
mands that  the  State  shall  exercise  due  care  over  the  prisoner's  health, 
it  comprises  a  question  that  demands  consideration  in  a  text-book  of 
hygiene. 

There  is  now  a  general  concurrence  of  opinion  that  the  State,  in 
depriving  any  person  of  liberty,  has  no  right  to  subject  the  individual 
suffering  such  deprivation  to  any  danger  of  disease  or  death.  In 
other  words,  the  State  has  no  right  to  abbreviate  the  life  of  the  convict 
sentenced  to  prison.  This  proposition  requires  that  the  State  see  to 
it  that  the  prisoner  is  well  fed,  well  clothed,  and  well  housed ;  that  he 
shall  be  well  cared  for  when  sick,  and  that  when  his  term  of  imprison- 
ment expires  he  shall  be  set  at  liberty,  with  only  such  effect  upon  his 
normal  expectation  of  life  as  would  result  from  the  ordinary  wear 
and  tear  of  life  upon  his  health. 

It  must  be  confessed,  however,  that  the  State  is  very  far  short 
of  attaining  this  object.  The  mortality  of  convicts,  even  in  the  best- 
regulated  prisons,  where  especial  attention  is  paid  to  the  sanitary  re- 
quirements of  such  buildings,  is  three  times  as  great  as  among  work- 
men in  mines,  confessedly  one  of  the  most  dangerous  occupations.  If 
insurance  companies  desired  to  insure  the  lives  of  prisoners,  the  com- 
panies would  be  obliged,  in  order  to  secure  themselves  against  loss, 
to  make  the  premium  equivalent  to  an  advance  in  age  of  twenty 
years.  This  means  that  a  free  person  has  as  long  expectation  of  life 
at  40  years  as  a  prisoner  has  at  20.  Attention  is  again  called  to  the 
fact  that  the  conditions  in  the  most  favorably  situated  and  liberally 
managed  prisons  only  are  here  considered.  What  the  results  are  in 
other  institutions,  less  favorably  constructed  and  managed,  will  be 
apparent  from  the  following  brief  statement :  Mr.  George  W.  Cable^ 
has  shown  that  in  some  of  the  prisons  in  the  Southern  States,  under 
the  vicious  lease  system,  the  mortality  is  eight  to  ten  times  greater 
than  in  properly  constructed  and  managed  prisons  elsewhere.  In 
Louisiana,  for  example,  14  per  cent,  of  all  the  prisoners  died  in  1881; 


'■  Century  Magazine,   February,  1884. 


350  TEXT-BOOK  OF  HYGIENE. 

and  in  the  convict  wood-cutting  camps  of  the  State  of  Texas  one-half 
of  the  average  number  so  employed  during  1879  and  1880  died. 

The  mortality  of  prisoners  is  greatest  in  the  second,  third,  and 
fourth  year  of  their  confinement.  In  Millbank  Prison,  in  England, 
the  death-rate  per  1000  was  3.05  in  the  first  year,  35.64  in  the  sec- 
ond, 52.26  in  the  third,  57.13  in  the  fourth,  and  44.17  in  the  fifth 
years  of  imprisonment. 

The  diseases  most  frequent  among  prisoners  are  pulmonary 
phthisis  and  diseases  of  inanition,  manifested  by  general  dropsy. 
Consumption  furnishes  from  40  to  80  per  cent,  of  all  deaths.  When 
prisoners  are  attacked  b)^  acute  febrile  or  epidemic  diseases  (small-pox, 
cholera,  dysentery),  the  mortality  is  much  higher  than  among  per- 
sons in  a  state  of  liberty.  This  fatality  is  due  to  an  anemic  or 
cachectic  condition,  which  has  been  called  "the  prison  cachexia," — a 
depravement  of  constitution  which  yields  readily  to  the  invasion  of 
acute  diseases.  Eecently  a  number  of  model  prisons  have  introduced 
modem  sanatorium  treatment  of  consumptive  prisoners. 

Prisons  should  be  built  upon  a  healthy  site,  be  properly  heated 
and  ventilated,  have  an  abundant  water-supply,  and  be  supplied  with 
facilities  for  a  prompt  and  thorough  removal  of  sewage.  Baths  and 
lavatories  should  be  conveniently  arranged  in  order  that  thorough 
cleanliness  can  be  enforced. 

The  problem  of  feeding  prisoners  requires  careful  study.  The 
food  should  not  only  be  sufficient  in  quantity  and  of  good  quality, 
but  it  should  be  well  cooked,  and  the  bill-of-fare  varied  often  in  order 
to  avoid  creating  a  disgust  by  an  everlasting  sameness.  Prisoners 
often  suffer  from  nausea  and  other  digestive  derangements,  brought  on 
solely  by  the  monotonous  character  of  the  daily  food. 

In  workshops  and  sleeping-rooms,  dormitories  or  cells,  the  cubic 
air-space  allowed  to  each  inmate  should  not  be  less  than  17  cubic 
metres,  with  proper  provision  for  ventilation.  The  use  of  dark  or 
damp  cells  as  places  of  confinement  is  a  relic  of  the  barbarism  in  the 
treatment  of  convicts  against  which  John  Howard  raised  his  voice  so 
effectively  in  the  last  century.  An  abundance  of  sun-light  should  be 
admitted  into  every  room  in  which  a  human  being  is  confined. 

An  important  hygienic  measure  is  daily  exercise  in  the  open  air. 
It  should  be  regularly  enforced,  and  its  modes  frequently  varied  in 
order  that  it  may  not  degenerate  into  a  mere  perfunctory  performance. 

Punishment  for  infractions  of  the  prison  discipline  should  be  in- 
flicted without  manifestation  of  passion,  and  only  under  the  im- 
mediate direction  of  some  official  responsible  to  the  State.    It  is  ques- 


PRISON  HYGIENE.  351 

tionable  whether  physical  punishments,  such  as  whipping,  tricing  up 
by  the  thumbs  with  the  toes  just  touching  the  floor,  bucking  and 
gagging,  and  similar  barbarities  should  be  permitted  under  any  con- 
ditions. The  permission  to  exercise  such  power  is  extremely  liable 
to  be  abused  by  officials.  The  system  of  leasing  out  prisoners  to  pri- 
vate parties  which  prevails  in  some  of  the  southern  United  States 
is  vicious  in  the  extreme,  because  it  places  the  convict  under  the  con- 
trol of  persons  not  responsible  to  the  State,  and,  in  the  majority  of 
instances,  morally  unfitted  to  wield  the  power  of  inflicting  punish- 
ment. 


QUESTIONS  TO  CHAPTER  XII. 

PRISON  HYGIENE. 

How  does  the  mortality  of  those  who  are  in  prison  compare  with  those 
of  the  same  age  who  are  free?  What  philanthropists  called  early  attention 
to  the  abuses  of  prisons  and  prisoners?  What  fundamental  propositions  now 
practically  govern  prison  legislation?  Why  must  the  State  exercise  due  care 
over  the  prisoner's  health?  What  must  the  State  do  to  attain  this  object? 
Does  it  succeed  in  doing  it?  How  does  the  excessive  mortality  compare  with 
that  of  dangerous  occupations?  How  does  the  expectation  of  life  compare 
with  that  of  those  outside  of  prison?  What  is  the  mortality  where  the  lease- 
system  obtains?  When  is  the  mortality  among  prisoners  greatest?  What 
diseases  are  most  frequent  among  prisoners?  What  is  the  effect  of  acute 
febrile  or  epidemic  diseases  upon  prisoners?     To  what  is  this  due? 

What  principles  should  be  observed  in  prison  construction?  What  points 
should  be  particularly  observed  regarding  the  food  of  prisoners?  How  much 
air-space  should  be  allotted  to  each  prisoner,  whether  in  workshops  or  cells? 
What  precautions  should  be  taken  against  dampness  and  absence  of  simlight? 
What  is  another  important  measure  that  should  be  enforced  daily?  How 
should  all  punishments  be  inflicted,  and  what  ones  should  be  prohibited? 
What  can  be  said  of  the  lease  system? 


(352) 


CHAPTER  Xni. 

PERSONAL  HYGIENE. 

All  sanitary  and  hygienic  precautions  relate  more  or  less  directly 
to  the  person,  but  those  princip'es  which  concern  most  intimately 
the  habits  and  body  of  the  individual,  rather  than  his  surroundings 
and  environment,  are  conveniently  grouped  in  a  class  denominated 
Personal  Hygiene. 

EXERCISE  AND  TRAINING. 

Exercise  is  the  performance  of  work,  or  overcoming  resistance. 
To  be  efficacious  from  a  hygienic  standpoint,  it  must  affect  not  only 
all  the  voluntary  muscles,  but  every  organ  and  tissue  of  the  body. 

The  healthy  functions  of  the  bodily  organs  can  only  be  main- 
tained by  more  or  less  constant  use.  A  muscle  or  other  organ  that 
is  unused  soon  wastes  away,  or  becomes  valueless'  to  its  possessor. 
On  the  other  hand,  trained  use  of  the  various  organs  makes  them  more 
effective  for  the  performance  of  their  functions.  Thus,  by  practice, 
the  eye  can  be  trained  to  sharper  vision,-  the  ear  to  distinguish  slight 
shades  of  sound,  the  voice  to  express  varying  emotions,  -the  tactile 
sense  to  accurately  appreciate  the  most  minute  variations  of  surface 
and  temperature,  and  the  hand  to  greater  steadiness  or  the  perform- 
ance of  diihcult  and  complex  feats.  The  effectiveness  of  other  organs, 
muscles,  or  groups  of  muscles  can  also  be  increased  by  systematic 
training,  as  is  seen  in  the  athlete  and  gymnast. 

When  a  muscle  contracts,  the  flow  of  blood  through  it  is  in- 
creased. Hence,  contraction  of  a  muscle,  which  consumes  or  con- 
verts stored-up  energy,  at  the  same  time  draws  upon  the  circulation 
for  a  new  supply  of  food-material  to  replace  that  consumed.  The 
activity  of  the  circulation  through  a  muscle  in  action  results  in  in- 
creased nutrition  and  growth  of  the  muscle. 

During  muscular  action  the  activity  of  the  respiratory  process  is 
increased.  A  larger  quantity  of  air  is  taken  into  the  lungs,  more 
oxygen  is  absorl)ed  l:)y  the  blood,  and  an  increased  elimination  of  car- 
bon dioxide  takes  place.  The  experiments  of  Pettenkofer  and  Voit 
show  that,  while  in  a  state  of  rest  the  average  absorption  of  oxygen 
in  twelve  hours  amounted  to  708.9  grammes,  during  work  the  amount 
renr-hf'fl  954.5  grammes.     For  the  same  period  the  elimination  of  car- 

23  (353) 


354  TEXT-BOOK  OF  HYGIENE. 

bonic  dioxide  was:  during  rest,  911.5  grammes;  during  work.  1384.2 
grammes. 

Upon  the  circulation  muscular  exercise  likewise  exerts  a  manifest 
influence.  The  action  of  the  heart  is  increased  both  in  force  and  fre- 
quenc}^,  the  arteries  dilate,  and  the  blood  is  sent  coursing  through  the 
s^'stem  more  rapidly  than  when  the  body  is  at  rest. 

Cutaneous  transpiration  is  also  promoted  by  muscular  exercise. 
In  this  way  some  of  the  effete  matters  in  the  system  are  removed,  being 
held  in  solution  and  carried  through  the  skin  in  the  per'^piration, 
helping  out  the  kidneys  in  the  performance  of  their  function,  and 
saving  them  from  undue  wear  and  tear. 

There  can  be  no  question  that  systematic  training  of  the  mus- 
cles has  a  favorable  influence  upon  health  and  longevity.  Persons 
who  are  actively  engaged  in  physical  labor,  other  things  being  equal, 
are  healthier,  happier,  and  live  longer  than  those  whose  occupation 
makes  slight  demands  upon  their  muscular  system.  In  default  of 
an  active  occupation  the  latter  class  is  forced,  if  good  health  is  de- 
sired, to  adopt  some  form  of  exercise  which  will  call  the  muscles  into 
activity. 

The  principal  methods  of  physical  training  are  walking  or 
running,  rowing,  swimming,  out-of-door  games,  such  as  golf,  tennis, 
foot-ball,  and  base-ball,  and  the  various  in-door  gymnastic  exercises. 
Eapid  walking  or  running  is  one  of  the  best  methods  of  physical  exer- 
cise, for,  not  only  are  the  muscles  of  the  legs  and  thighs  developed, 
but  the  capacity  of  the  chest  is  increased — one  of  the  principal  objects 
of  physical  training.  By  combining  walking  with  some  form  of 
in-door  g}Tnnastics,  such  as  practice  with  dumb-bells,  Indian  clubs, 
rowing-machines,  or  pulley-weights,  nearly  all  the  good  effects  of  the 
most  elaborate  system  of  training  can  be  obtained. 

For  the  gymnastic  exercises  various  forms  of  useful  labor  may 
be  substituted  with  advantage,  such  as  wood-chopping  or  sawing,  or 
moderate  work  at  any  physical  labor. 

The  scheme  of  studies  in  our  public-school  system  should  include 
physical  training  for  both  sexes.  This  is  a  question  not  merely  of 
individual,  but  of  national  importance.  Weak  and  unhealthy  chil- 
dren are  not  likely  to  grow  up  into  strong  and  healthy  men  and 
women;  and  the  latter  are  necessary  for  the  perpetuity  of  the  nation. 
The  time  seems  to  have  arrived  when  physical  education  should  no 
longer  be  looked  upon  as  a  whim  of  unpractical  enthusiasts  and  hobby- 
riders,  bvit  as  an  indispensable  element  in  every  school  curriculum. 

There  is  a  tendency  among  instructors  in  physical  training  to 


EXERCISE   AND   TRAINING. 


855 


make  their  systems  too  complicated,  or  dependent  upon  expensive  or 
cumbersome  apparatus.  This  is  to  be  deprecated.  All  the  muscles 
of  the  body  can  be  called  into  action  by  very  simple  exercises,  easily 
learned  and  readily  carried  out. 

An  important  preliminary  to  all  methods  of  training  is  a  thorough 
physical  examination  of  the  pupil  by  a  competent  physician,  in  or- 
der to  determine  whether  certain  exercises  are  allowable.  For  ex- 
ample, in  all  organic  heart  affections  exercises  of  a  violent  character 
must  be  interdicted.  A  boy  or  man  with  valvular  disease  of  the 
heart  cannot  run,  row,  or  swim  with  safety.  The  organ  is  easily 
overtasked  in  this  condition  and  liable  to  fail  in  its  function. 

One  of  the  simplest  and  best  methods  to  cause  the  pupil  to  as- 
sume a  correct  position  of  the  body,  and  to  acquire  ease  and  grace  in 
his  movements,  is  to  teach  him  the  "setting-up,"  as  practiced  in  the 
United  States  arniy.^ 

In  walking,  a  free,  swinging  step  should  be  acquired,  with  the 
head  erect,  shoulders  thrown  back,  and  the  chest  well  to  the  front,  the 
whole  body  from  the  hips  upward  inclining  slightly  forward.  The 
clothing  should  be  loose  around  the  upper  part  of  the  body,  in  order 
not  to  interfere  with  the  freest  expansion  of  the  chest,  and  to  give  the 
lungs  and  heart  ample  room  for  movement.  Even  in-door  gymnastic 
exercises  alone,  when  practiced  under  intelligent  provision,  will  ac- 
complish very  favorable  results,  as  shown  by  the  following  table : — 

Table  LIV. 

Showing  Average  State  of  Development  on  Admission  to  Gymnasium  ;  Average  State 
of  Growth  and  Development  after  Six  Months'  Practicing  Two  Hours  a  Week, 
and  Average  Increase  During  that  Time.  {Bowdoin  College  Gymnasium,  under 
Dr.  D.  A.  Sargent.  Two  Hundred  Students  from  the  Classes  of  1873  to  1877, 
inclusive.     Average  Age,  18.3  Tears.  )2 


Height 

Weight 

Chest  (inflated I    . 
Chest  (contracted) 

Forearm 

Upper  arm  (flexed) 
Shoulders  (width) 

Hips- 

Thigh 

Calf 


On  Admission. 


170.0  cm. 
60.7  kg. 
87-5  cm. 

80.6  " 
25.0  " 
27.5    " 

38.7  " 
78.7  " 
48.7  " 
31.2    " 


After  Six 

Months' 

Practice. 


170.6  cm. 
61.6  kg. 
91.8  cm. 
82.4 
26.8 
29.0 
40.5 
84.4 
52.6 
38.0 


Average 
Increase. 


0.6  cm. 
900.0  gms. 
4.3  cm. 
1.8    " 
1.8     " 
1.5    " 

1.8  " 

5.7  " 

3.9  " 

1.8  " 


'  Upton's  Infantry  Tactics.     School  of  the  Soldier,  Lesson  I. 
'■'Apparatus  used:      Wcif^lits,  4500  to   6750  grammes;     Dumb-bells,   1125 
grammes;     Indian  clubs,    1575   grammes;     Pulleys. 


356  TEXT-BOOK  OF  HYGIENE. 

The  table  on  the  following  page  shows  the  average  rate  of  in- 
crease in  development  in  a  two  years'  and  a  four  years'  class  in  Am- 
herst College,  and  also  the  percentage  of  increase  in  one  four  years' 
class  from  entrance  to  graduation.  The  interesting  fact  has  been 
brought  out  by  Mr.  Delabarre  that  tobacco-smoking  has  a  decidedly 
deleterious  effect  upon  the  rate  and  percentage  of  physical  develop- 
ment in  students.  In  weight  non-smokers  gained  24  per  cent,  over 
smokers;   in  height,  37  per  cent.,  and  in  chest-girth,  42  per  cent. 

However  necessary  for  the  preservation  of  health  physical  exer- 
cise may  be,  overexertion  should  be  carefully  avoided.  Overstrain 
and  hypertrophy  of  the  heart  are  often  the  results  of  excessive  exer- 
tion. Dr.  Da  Costa  has  described  a  form  of  "irritable"  and  weak 
heart  occurring  especially  among  soldiers,  which  he  has  clearly 
traced  to  overexertion.  Severe  labor  and  violent  athletic  exercises 
have  been  followed  by  like  serious  results.  Long-distance  pedestrian- 
ism  has  furnished,  within  recent  years,  quite  a  number  of  individuals 
who  were  broken  down  in  health  by  the  excessive  strain  on  the  physi- 
cal organization  involved.  Cardiac  strain  is  not  infrequent  among 
this  class.  Spasm,  paralysis,  or  atrophy  of  muscles  sometimes  results, 
when  these  are  exhausted  by  uninterrupted  or  excessive  exercise.  This 
effect  is  shown  by  writers'  and  telegraphers'  cramp,  and  similar  affec- 
tions. For  these  reasons  it  is  important  that  exercise  both  for  health 
and  for  actual  work  should  be  so  regulated  as  to  conduce  to  the  indi- 
vidual's benefit,  and  not  to  his  detriment. 

As  to  the  amount  of  exercise  required.  Dr.  Egbert  says  (Hygiene 
and  Sanitation,  p.  283)  :  "It  is  hard  to  determii^e  how  much  exercise 
any  given  person  ought  to  take,  as  the  personal  equation  varies  so 
much.  The  average  healthy  man  should  probably  do  work  equivalent 
to  150  foot-tons  daily.  The  work  of  walking  on  a  level  at  the  rate 
of  three  miles  per  hour  is  said  to  be  equal  to  that  of  raising  one- 
twentieth  of  the  body-weiglit  through  the  distance  walked.  Accord- 
ing to  this,  a  man  of  150  pounds  in  walking  one  mile  does  work  equal 
to  17.67  foot-tons,  and  his  total  daily  physical  labor  should  be  equiva- 
lent to  walking  about  nine  miles  at  the  above  rate  to  get  the  proper 
amount  of  daily  exercise.  This  seems  like  an  excessive  amount,  but 
if  the  actual  physical  work  of  one's  customary  vocation  be  taken  from 
this,  it  will  not  leave  so  very  much  for  the  daily  health-task;  and 
while  the  natural  disinclination  of  many  to  exercise  grows  stronger 
by  indulgence,  and  while  urgent  reminders  are  wanting  and  the  evils 
arising  from  the  neglect,  iabuse,  or  misuse  of  exercise  are  not  so  very 
immediate  or  apparent,  the  latter  are  still  certain  to  result,  and  are 
not  at  all  consistent  with  good  and  perfect  health." 


BATHS  AND  BATHING. 


357 


Table  LV. 

Showing  Physical  Gains  of  Students  in  Amherst  College  During  a  Part  and  During 
the  Wiole  of  the  College  Course.  {Prof.  E.  Hitchcock,  Dr.  H.  H.  Seelye,  and 
Mr.  F.  A.  Delabarre. ) 


Weight     

Height 

fcjternum  ....'.. 

Navel 

Pubes 

Knee 

Sitting 

Girth,  Head 

Neck 

Chest  repose  .... 

Chest  full 

Belly 

Hips 

Right  th^gh    .  .  .   . 

Left  thigh 

Right  knee 

Left  knee 

Right  calf 

Left  calf 

Right  instep  .   .  .   . 

Left  instep 

Upper  right  arm  .   . 

U.  R.  A.  contracted 

Upper  left  arm     .   . 

Right  elbow  .  .  .   . 

Left  elbow  .   .*.  .   . 

Right  forearm  .  .   . 

Left  forearm  .  .  .   . 

Right  wrist    .  .  .   . 

Left  wrist 

Breadth,  Head 

Neck 

Shoulders    

Nipples 

Waist 

Hips 

Right-shoulder  elbow  . 
Left-shoulder  elbow  .  . 
Right  elbow-t'p    .   .  .   . 

Left  elbow-tip 

Length,  Right  foot    .   . 

Left  foot 

Stretch  of  arms  .  .  .  . 
Horizontal  length  .  .  . 
Strength 

Lungs 

Back 

Chest  dip 

Chest  pull  up    .   .  . 

Legs 

Right  forearm  .   .   . 

Left  forearm  .  .  . 
Capacity  of  lungs    .  .  . 


Gain  of  Two 
Years'  Class. 


Metric. 


.2.6 
.11 
.3 
.4 
.8 
.4 
.14 
.5 
.10 
.14 
.9 
.10 
.15 
.19 
.13 
.4 
.3 
.9 
.11 
.2 
.2 
.13 
.11 
.14 
.6 
.6 
.4 
.3 
.1 
.2 
.1 
.2 
.11 
.7 
.2 
.2 
.3 
.2 
.2 
.2 
.2 
.1 
.19 
.14 
».73 

a. 30 

.2.8 
i>2.6 
bl.l 

a, .33 

a. 5 

a. 5 

cl.2 


English. 


db.72 
.43 
.11 
.15 
.31 
.15 
.55 
.19 
.39 
.55 
.35 
.39 
.59 
.74 
.51 
.15 
.11 
.,35 
.43 
.07 
.07 
.51 
.43 
.55 
.23 
.23 
.15 
.11 
.03 
.07 
.03 
.07 
.43 
.27 
.07 
.07 
.11 
.07 
.07 
.07 
.07 
.03 
.74 
.55 
d  160.9 
d.66 
d61.7 


a  72.7 
dU  0 
dll.O 

e73.2 


Gain  of  Four 
Years'  Class. 


Metric. 


5.40 
.16 
.11 
.9 
.5 
.12 
.18 
.7 
.14 
.41 
.34 
.41 
.36 
.24 
.25 
.6 
.7 
.13 
.10 
.8 
.9 
.13 
.17 
.16 
.6 
.5 
.5 
.6 
.2 
.3 
.3 
.4 
.19 
.13 
.9 
.11 
.4 
.4 
.10 
.6 
.5 
.4 
.24 
.20 
.82 
.64 
.28 
2.3 
1.2 
.37 
.7 
.5 
3.6 


English. 


11.8 
.63 
.43 
.35 
.19 
.47 
.7 
.27 
.55 
1.61 
1.33 
1.61 
1.41 
.94 
.98 
.23 
.27 
.51 
.39 
.31 
.35 
.51 
.66 
.62 
.23 
.19 
.19 
.23 
.07 
11 
.11 
.15 
.74 
.51 
.35 
.43 
.15 
.15 
.39 
.23 
.19 
.15 
.94 
.78 
180.8 
1.41 
61.7 


81.5 

15.4 

11.0 

219.6 


Per  Cent. 

of 

Increase 

in  Class 

of  '91. 


8.9 
0.6 
0.7 
1.2 
:s.3 
0.4 
1.3 
0.5 
2.5 
3.0 
1.0 
4.1 
2.4 
3.0 
3.1 
0.8 
1.1 
2.8 
2.3 
0.8 
0.8 
6.3 
6.4 
7.8 
3.5 
3.5 
3.3 
3.1 
0.0 
06 
0.6 
1.8 
3.6 
6.4 
3.4 
1.8 
1.1 
0.8 
1.5 
1.5 
1.1 
1.1 
1.3 
0.6 
26.9 
27.8 
24.0 
38.0 
20.5 
26.0 
23.7 
16.6 
4.0 


Weij 

8.1 


;ht, 


Height, 
2.72 


Giith. 

2.72 


Breadth, 
2.93 


Strength, 
25.31 


Capacity, 
4.00 


A  total  average  gain 
of  5.87  per  cent. 


a — Kilos,    b — Units. 


c— Litres,    d— Pounds,    e— Cubic  inches.    All  others.  Millimetres, 
and  Inches  and  Tenths. 


BATHS   AND   BATHING. 

T]](i  most  iiriportaiit  sanitary  object  of  bathing  is  cleanliness.     A 
secondary  object  of  the  bath  is  to  stimulate  the  functions  of  the  skin, 


358  TEXT-BOOK  OF  HYGIENE, 

and  to  produce  a  general  feeling  of  exhilaration  of  the  bod3^  Baths 
are  used  of  various  temperatures.  A  cold  bath  has  a  temperature  of 
from  4°  to  24°  C.  (40°  to  75°  F.)  ;  a  tepid  bath  from  24°  to  30°  C. 
(75°  to  85°  F.)  ;  a  warm  bath  from  30°  to  38°  C.  (85°  to  100°  F.) ; 
and  a  hot  bath  from  38°  to  43°  C.  (100°  to  110°  F.). 

Tepid,  warm,  or  hot  baths  are  used  principally  as  cleansing 
agents  or  as  therapeutic  measures.  They  cause  dilatation  of  the  cu- 
taneous capillaries,  diminish  blood-pressure,  and  reduce  nervous 
excitability.  The  hot  bath  is  also  a  method  of  restoring  warmth  to 
the  body  in  cases  of  shock,  or  to  remove  the  immediate  effects  of 
injurious  exposure  to  low  temperature. 

The  so-called  Eussian  and  Turkish  baths,  so  popular  in  the  larger 
cities  of  this  country,  are  modifications  of  vapor-  and  hot-air  baths, 
or  rather  combinations  of  these  with  cold  baths.  The  Turkish  bath 
is  especially  to  be  recommended  for  its  depurative  and  invigorating 
effects. 

Cold  baths  are  used  not  merely  for  their  cleansing  effects,  but 
principally  for  their  stimulating  effects  upon  the  system.  When  first 
plunging  into  a  cold  bath  there  is  usually  a  momentary  shock;  the 
respiration  is  gasping,  and  the  pulse  is  increased  in  frequency.  These 
symptoms  disappear  in  a  few  moments,  however,  and  reaction  follows. 
To  a  healthy  person  a  cold  bath  is  a  delightful  general  stimulant, 
removing  the  sense  of  fatigue  after  physical  exertion  and  causing  an 
extremely  refreshing  sensation  throughout  the  body. 

As  a  therapeutic  measure,  the  cold  bath  has  a  wide  field  of  use- 
fulness. For  the  reduction  of  the  bodily  temperature  in  fevers  and 
inflammatory  diseases,  and  especially  in  heat-stroke,  it  is  more  prompt 
and  effective  than  any  other  agent  at  the  command  of  the  physician. 

Sea-bathing. — The  most  stimulating  form  of  the  cold  bath  is 
doubtless  the  salt-water  bath  as  taken  at  the  sea-shore.  The  revul- 
sive effect  of  the  impact  of  the  waves  and  breakers  upon  the  skin  and 
the  stimulation  due  to  the  saline  constituents  of  the  sea-water  heighten 
the  invigorating  effects  of  the  simple  cold  bath.  The  beneficial  results 
of  sea-bathing  are,  however,  not  entirely  due  to  the  bath,  but  are  to 
a  great  degree  dependent  upon  the  bracing  air  of  the  sea-shore,  absence 
of  the  care  and  anxieties  of  business,  and  the  temporary  change  in 
food  and  habits  that  a  residence  at  the  sea-side  involves.  Neverthe- 
less, salt-water  baths  are  more  stimulant  to  the  skin  than  those  of 
simple  water,  and  part  of  the  good  effects  of  sea-bathing  can  often  be 
obtained  from  a  salt-water  bath  taken  at  home.     The  following  mix- 


BATHS  AND  BATHING.  359 

ture  of  salts  dissolved  in  about  125  litres  of  water  for  one  bath  makes 
a  fairly  good  substitute  for  a  sea-bath : — 

Take  of  Chloride  of  sodium    (common  salt)  ....    4       kilogrammes. 
Sulphate   of  sodium    (Glauber's   salt)  .  .   2  " 

Chloride  of  calcium    %  kilogramme. 

Chloride   of   magnesium 1%  " 

There  is  a  prevalent  popular  belief  that  it  is  extremely  dangerous 
to  enter  a  cold  bath  when  heated  or  perspiring.  The  author  is  of 
the  opinion  that  this  belief  is  erroneous.  The  stimulant  and  brac- 
ing effects  of  the  cold  bath  are  most  manifest  if  it  be  taken  while  the 
individual  is  very  warm  or  bathed  in  perspiration.  Several  years  ago 
the  author  made  a  series  of  observations  upon  himself  to  determine 
the  effects  of  the  cold  bath  when  the  body  was  warm.  Every  afternoon 
a  free  perspiration  was  provoked  by  a  brisk  walk  of  about  2  kilo- 
metres in  the  sun.  As  soon  as  the  clothing  could  be  cast  off,  and  while 
the  body  was  still  freely  perspiring,  a  plunge  was  taken  into  a  fresh- 
water bath  of  about  15.5°  C.  (60°  F.).  No  ill  results  followed;  on 
the  contrary,  the  sensation  immediately  following  the  bath,  and  for 
six  or  eight  hours  afterward,  was  exceedingly  pleasant.  The  health 
remained  perfect,  and  the  weight  decidedly  increased  during  the  two 
months  the  practice  was  continued.  There  is  probably  no  danger  to 
a  healthy  person  in  this  practice,  but  it  is  considered  advisable  to 
immerse  the  head  first  ("take  a  header"),  to  avoid  increasing  the 
blood-pressure  in  the  brain  too  greatly,  which  might  result  if  the  body 
were  gradually  immersed  from  the  feet  upward. 

The  following  series  of  rules  have  been  issued  by  the  English 
Eoyal  Humane  Society,  and  are  all  worth  observing  by  bathers : 
"Avoid  bathing  within  two  hours  after  a  meal.  Avoid  bathing  when 
exhausted  by  fatigue  or  from  any  other  cause.  Avoid  bathing  when 
the  body  is  cooling  after  perspiration.  Avoid  bathing  altogether  in 
the  open  air,  if,  after  having  been  a  short  time  in  the  water,  there 
is  a  sense  of  chilliness,  with  numbness  of  the  hands  and  feet;  but 
bathe  when  the  body  is  warm,  provided  no  time  is  lost  in  getting  into 
the  water.  Avoid  chilling  the  body  by  sitting  or  standing  undressed 
on  the  banks  or  in  boats,  after  having  been  in  the  water.  Avoid  re- 
maining too  long  in  the  water,  but  leave  the  water  immediately  if 
there  is  the  slightest  feeling  of  chilliness.  The  vigorous  and  strong 
may  bathe  early  in  the  morning  on  an  empty  stomach.  The  young, 
and  those  who  are  weak,  had  better  bathe  two  or  three  hours  after  a 
meal ;   the  best  time  for  such  is  from  two  to  three  hours  after  break- 


360  TEXT-BOOK  OF  HYGIENE. 

fast.  Those  who  are  subject  to  giddiness  or  faintness,  or  suffer  from 
palpitation  or  other  sense  of  discomfort  at  the  heart,  should  not  bathe 
without  first  consulting  their  medical  adviser." 

To  these  instructions  may  properly  be  added  that  a  warm  or 
hot  bath  should  be  avoided  if  the  person  is  liable  to  exposure  to  cold 
within  a  few  hours  after  the  bath;  that  women  should,  as  a  ru'e, 
not  take  a  cold  bath  while  menstruating,  or  during  the  last  two  months 
of  pregnancy;  and  that  persons  suffering  from  organic  heart  disease 
should  especially  avoid  surf-bathing. 

After  bathing  the  body  should  be  thoroughly  dried  with  soft 
towels,  otherwise  eczematous  eruptions  are  liable  to  follow  in  tlie 
parts  subject  to  friction  from  opposing  surfaces  of  the  skin,  as  in  the 
groins,  the  perineum  and  inner  surface  of  the  thighs,  the  armpits, 
or  the  under  surface  of  the  breasts  in  women  in  whom  these  organs 
are  large  and  pendant. 

Friction  of  the  skin  with  a  coarse  towel,  or  so-called  "flesh- 
brush,"  is  a  popular  practice,  but  is  not  to  be  universally  commended. 
The  hyperemia  of  the  surface  thus  produced  may  sometimes  induce 
cutaneous  diseases  (erythema,  eczema,  psoriasis)  in  those  predisposed. 

One  of  the  most  serious  dangers  of  cold  bathing,  but  which  is 
not  sufficiently  appreciated,  is  the  tendency  to  nausea  and  vomiting  if 
the  stomach  contains  much  food.  There  can  be  no  doubt  that  many 
cases  that  are  called  "cramp,"  and  which  frequently  result  in  drown- 
ing, are  due  to  this  cause.^ 

Cramps  of  the  various  muscles  sometimes  occur,  rendering  the 
bather  helpless,  and  if  in  deep  water  he  is  liable  to  drown  before  as- 
sistance can  reach  him. 

In  drowning  death  takes  place  by  asphyxia.  The  respiration  is 
arrested  by  the  submersion  of  the  head,  the  carbonized  blood  gradually 
poisons  the  system,  and  the  heart  ceases  to  beat.  So  long  as  the  heart 
will  react  to  its  appropriate  stimulus  the  person  may  be  restored  to 
life.  The  first  thing  to  do,  therefore,  after  a  recently-drowned  per- 
son is  taken  out  of  the  water,  is  to  attempt  to  re-establish  the  arrested 
respiration.  Several  methods  are  in  use  for  this  purpose.  Sylvester's 
is  one  of  the  simplest.     It  is  as  follows: — 

The  body  being  placed  on  the  back  (either  on  a  flat  surface  or, 
better,  on  a  plane  inclined  a  little  from  the  feet  upward),  a  firm 
cushion  or  similar  support  (a  coat  rolled  up  wil  answer)  should  be 
placed  under  the  shoulders,  the  head  being  kept  in  a  line  with  the 


^  So   far   as  the   author  is   aware.   Dr.   John  Morris,   of  Baltimore,   first 
called  especial  attention  to  this  source  of  danger. 


BATHS  AND  BATHING.  361 

trunk.  The  tongue  should  be  drawn  forward  to  raise  the  epiglottis 
and  uncover  the  windpipe.  The  arms  should  be  grasped  Just  above  the 
elbows  and  drawn  upward  until  they  nearly  meet  above  the  head,  and 
then  at  once  lowered  and  replaced  at  the  side.  This  should  be  imme- 
diately followed  by  pressure  with  both  hands  upon  the  belly.  Just 
below  the  breastbone.  The  process  is  to  be  repeated  fifteen  to  eighteen 
times  a  minute. 

Several  years  since  the  Michigan  State  Board  of  Health  published 
a  method  which  is  comprehensive,  effective,  easily  understood,  and 
readily  carried  out.  This  method  has  also  been  adopted  by  the  United 
States  Life- Saving  Service.  The  following  are  the  details  of  the 
Michigan  method: — 

Eule  1. — Eemove  all  the  obstructions  to  breathing.  Instantly 
loosen  or  cut  apart  all  neck-  and  waist-  bands;  turn  the  patient  on 
his  face,  with  the  head  down  hill;  stand  astride  the  hips  with  your 
face  toward  his  head,  and,  locking  your  fingers  together  under  his 
belly,  raise  the  body  as  high  as  you  can  without  lifting  the  forehead 
off  the  ground,  and  give  the  body  a  smart  Jerk  to  remove  mucus  from 
the  throat  andwater  from  the  windpipe,  hold  the  body  suspended  long 
enough  to  slowly  count  one — tivo — three — four — five,  repeating  the 
Jerk  more  gently  two  or  three  times. 

Rule  2. — Place  the  patient  on  the  ground  face  downward,  and, 
maintaining  all  the  while  your  position  astride  the  body,  grasp  the 
points  of  the  shoulders  by  the  clothing;  or,  if  the  body  is  naked, 
thrust  your  fiugers  into  the  armpits,  clasping  your  thumbs  over  the 
points  of  the  shoulders,  and  raise  the  chest  as  high  as  you  can  with- 
out lifting  the  head  quite  off  the  ground,  and  hold  it  long  enough 
to  slowly  count  one — tivo— three.  Replace  him  on  the  ground  with 
his  forehead  on  his  flexed  arm,  the  neck  straightened  out,  and  the 
mouth  and  nose  free;  place  your  elbows  against  [the  inner  surface] 
your  knees  and  your  hands  upon  the  sides  of  his  chest  over  the  lower 
ribs,  and  press  downward  and  inward  with  increasing  force  long 
enough  to  slowly  count  one — two.  Then  suddenly  let  go,  grasp  the 
shoulders  as  before,  and  raise  the  chest ;  then  press  upon  the  ribs,  etc. 
These  alternate  movements  should  be  repeated  ten  or  fifteen  times  a 
minute  for  an  hour,  at  least,  unless  breathing  is  restored  sooner.  Use 
the  same  regularity  as  in  natural  breathing. 

Rule  3. — After  breathing  has  commenced  restore  the  animal  heat. 
Wrap  him  up  in  warm  blankets,  apply  bottles  of  hot  water,  hot  bricks, 
or  anything  to  restore  heat.  Warm  the  head  nearly  as  fast  as  the  body 
lest  convulsions  come  on.     Rubbing  the  body  with  warm  cloths  or 


362  TEXT-BOOK  OF  HYGIENE. 

the  hands  and  slapping  the  fleshy  parts  may  assist  to  restore  warmth 
and  the  breathing  also. 

If  the  patieiit  can  surely  swallow,  give  hot  coffee,  tea,  milk,  or  a 
little  hot  sling.     Give  rpirits  sparingly,  lest  they  prodvice  depression. 

Place  the  patient  in  a  warm  bed,  and  give  him  plenty  of  fresh 
air.     Keep  him  quiet. 

Beware !  Avoid  delay.  A  moment  may  turn  the  scale  for  life 
or  death.  Dry  ground,  shelter,  warmth,  stimulants,  etc.,  at  this 
moment  are  nothing — artificial  breathing  is  everything — is  the  one 
remedy — all  others  are  secondary.  Do  not  stop  to  remove  wet  cloth- 
ing. Precious  time  is  wasted  and  the  patient  may  be  fatally  chilled 
by  exposure  of  the  naked  body,  even  in  summer.  Grive  all  your  at- 
tention and  efforts  to  restore  breathing  by  forcing  air  into,  and  out 
of,  the  lungs.  If  the  breathing  has  just  ceased,  a  smart  slap  on  the 
face  or  a  vigorous  twist  of  the  hair  will  sometimes  start  it  again,  and 
may  be  tried  incidentally.  Before  natural  breathing  is  fully  restored, 
do  not  let  the  patient  lie  on  his  back  unless  some  person  holds  the 
tongue  forward.  The  tongue  by  falling  back  may  close  the  windpipe 
and  cause  fatal  choking. 

Do  not  give  up  too  soon;  )^ou  are  working  for  life.  Any  time 
within  two  hours  you  may  be  on  the  very  threshold  of  success  without 
there  being  any  sign  of  it.*  ^ 

In  all  large  cities  and  towns  provision  should  be  made  for  free 
public  baths,  conducted  under  official  supervision,  and  for  the  especial 
use  and  benefit  of  the  poorer  classes.  General  cleanliness  is  not 
merely  a  factor  in  the  preservation  of  the  public  health,  but  there  is 
good  reason  to  believe  that  the  cause  of  good  order  and  decency  would 
likewise  be  promoted  by  furnishing  the  public  the  means  of  easily  and 
cheaply  keeping  clean.  Many  cities  in  the  country  have  established 
public  baths  upon  an  increasingly  generous  scale,  and  these  are  very 
popular  and  have  doubtless  been  of  great  benefit.  The  author  has 
shown^  that  about  five-sixths  of  the  inhabitants  of  the  large  cities  in 
the  United  States  have  no  facilities  for  bathing  except  such  as  are 
afforded  by  a  pail  of  water  and  sponge,  or  in  summer  the  proximity 
of  some  body  of  water  easily  accessible.  The  most  economical  and 
best  form  of  bath  for  public  use  would  doubtless  be  the  needle  or 
rain  bath  recommended  by  the  author  in  the  paper  referred  to.  Mr. 
W.  P.  Gerhard  has  also  stronglv  advocated  this  form  of  bath. 


*  Report  of  Michigan  State  Board  of  Health,   1874,  pp.  91-99. 
°  Address    in    State    Medicine,    Journal    American    Medical    Association, 
July  2,   1887. 


CLOTHING.  363 

It  would  be  well  if  boards  of  health  and  building  commissioners 
would  issue  no  permits  for  dwelling-houses,  the  plans  for  which  do 
not  include  proper  water-supply  and  bathing  facilities. 

CLOTHING. 

The  primary  object  of  clothing  is  the  protection  of  the  body 
against  the  injurious  influences  of  heat,  cold,  and  moisture.  Second- 
arily, the  moral  sense  of  civilized  communities  demands  that  the  nude 
human  body  shall  not  be  exposed  in  public.  Hence,  there  are  moral 
as  well  as  sanitary  reasons  for  the  wearing  of  clothing ;  only  the  latter 
can  be  considered  in  this  place. 

Bodies  radiate  or  absorb  heat  accordingly  as  they  are  surrounded 
by  a  medium  having  a  lower  or  a  higher  temperature  than  themselves. 
In  order,  therefore,  to  avoid  chilling  of  the  human  body  if  exposed 
to  a  temperature  below  37°  C.  (98.6°  F.),  clothing  must  be  worn  to 
prevent  or  retard  radiation  of  the  body-heat.  Exposure  of  the  un- 
protected body  to  a  low  temperature  would  not  only  cause  chilling 
of  the  surface  owing  to  the  rapid  loss  of  heat,  but  would  incidentally 
produce  congestion  of  internal  organs  by  causing  constriction  of  the 
superficial  capillaries. 

Clothing  is  also  worn  as  a  protection  against  great  heat.  The 
head,  especially,  needs  protection  from  the  sun's  rays.  Evidence  is 
accumulating  to  the  effect  that  direct  sun-light,  if  excessive,  is  equally 
injurious. 

The  materials  from  which  clothing  is  made  are,  principally, 
cotton,  linen,  wool,  silk,  and  the  skins  of  animals.  Of  these,  prob- 
ably the  most  universally  used  is  cotton.  It  is  cheap,  durable,  does 
not  shrink  when  wet,  absorbs  little  water,  and  conducts  heat  readily. 
It  is  therefore  especially  valuable  for  summer  garments,  allowing 
rapid  dissipation  of  the  body-heat  and  evaporation  of  the  perspiration. 

Linen  conducts  heat  even  better  than  cotton,  and  is  for  this 
reason  largely  used  for  summer  clothing.  Its  principal  advantage 
over  cotton  is  that  it  is  more  durable  and  less  harsh  to  the  skin. 

Wool  absorbs  water  readily  and  is  a  bad  conductor  of  heat.  It 
is  therefore  valuable  as  a  winter  garment,  retarding  radiation  from 
the  body.  Woolen  undergarments  should  be  worn  at  all  seasons,  in 
order  to  prevent  too  rapid  changes  of  the  surface,  and  so  invoking  dis- 
eases depending  upon  chilling  of  the  body.  Clothing  of  pure  wool 
(flannels)  is  lia})le  to  irritate  the  skin  of  some  persons.  A  mixture  of 
wool  and  collon,  known  us  "Saxony  wool,"  is  softer  and  less  irritating, 
and  makes  a  serviceable  substitute  for  pure  wool. 


364  TEXT-BOOK  OF  HYGIENE. 

Silk  is  often  used  for  undergarments.  It  is  light,  soft,  and  a 
bad  conductor  of  heat. 

Linen-mesh  combines  the  advantage  of  both  cotton  and  wool,  and 
is  an  excellent  material  for  undergarments. 

The  skins  of  anima's,  with  the  fur  on,  are  often  used  for  outside 
clothing.  They  furnish  great  protection  against  severe  cold.  The 
skin  is  impermeable  to  wind  and  rain,  while  the  thick,  pilous  covering 
of  fur  retards  to  a  very  great  degree  the  radiation  of  heat.  In  British 
America,  the  Northwestern  States  and  Territories,  and  in  the  Arctic 
regions,  the  use  of  skin  clothing  is  necessary  for  comfort. 

As  a  protection  against  moisture  (rain  and  snow)  rubber  doth  is 
used  for  overcoats,  etc.,  but  it  is  not  now  so  much  employed  as  for- 
merly, because,  while  it  serves  effectually  in  keeping  out  the  rain,  it 
prevents  evaporation  of  the  perspiration,  increasing  the  liability  to 
chill,  and  rendering  the  person  wearing  it  very  uncomfortable,  except 
in  cold  weather.  Outer  garments  waterproofed  after  the  method 
known  as  the  "Cravenette"  process,  and  made  of  almost  any  mate- 
rial desired,  are  now  substituted. 

Leather  is  used  almost  exclusively  in  the  manufacture  of  foot- 
wear. It  is  sometimes  used,  however,  for  other  articles  of  clothing, 
such  as  coats,  trousers,  etc.  It  furnishes  most  effective  protection 
against  cold. 

The  color  of  the  clothing  is  of  great  importance.  Exposed  to  the 
sun,  white  wool  or  silk  absorb  very  little  more  heat  than  linen  or 
cotton,  but  the  same  material,  of  different  colors,  when  exposed  to 
the  sun's  rays,  exhibits  marked  differences  in  absorptive  capacity. 
The  following  table  shows  the  results  of  some  experiments  of  Petten- 
kofer.     The  material  used  was  cotton  shirting  of  the  colors  named :— - 

White    absorbed 100  heat  units. 

Light  Sulphur  Yellow  absorbe  1 102 

Dark  Yellow  absorbed 1  '0 

Light    Green    absorbed 155 

Turkey  Red  absorbed 165 

Dark  Green  absorbed 1C8 

Light    Blue    absorbed 198 

Black    absorbed 208 

When  protected  from  the  sun's  rays,  liowever,  the  material  be- 
comes important  and  the  color  is  of  little  consequence.  Wool,  being 
a  bad  conductor  of  heat,  retards  radiation  from  the  body,  and  is 
hence  the  best  material  for  winter  clothing. 

Gases  and  vapors  are  absorbed  by  clothing  and  also  disease-germs 


CLOTHING.  365 

may  be  conveyed  from  place  to  place.  It  has  been  found  that  woolen 
clothing  possesses  this  power  of  absorption  to  a  much  greater  degree 
than  linen  or  cotton.  The  bad  odor  of  a  crowded  room  or  of  tobacco- 
smoke  frequently  clings  to  woolen  garments  for  days,  although  they 
may  be  exposed  constantly  to  the  air  during  the  interval.  It  would 
be  advisable,  therefore,  that  physicians  attending  infectious  diseases, 
hospital  attendants  and  nurses,  should  wear  linen  or  cotton  clothing 
instead  of  woolen. 

Clothing  should  be  made  to  fit  properly.  It  shouM  not  restrain 
muscular  movements,  obstruct  the  circulation,  or  compress  organs. 
Hence,  corsets,  belts,  and  garters  are  to  be  condemned.  It  is  a  fact  of 
common  observation  that  moderately  loose  clothing  is  warmer  than 
close-fitting. 

Especial  attention  should  be  given  to  the  shape  and  fitting  of  foot- 
wear. Boots  and  shoes  are  usually  made  with  little  regard  to  the 
physiological  anatomy  of  the  foot,  and  as  a  result  the  feet  of  most 
Americans  are  deformed,  beauty  and  usefulness  being  in  a  great  de- 
gree sacrificed  to  the  Moloch  of  fashion.*' 

Dyes  used  for  coloring  fabrics  are  sometimes  poisonous.  The 
author  has  repeatedly  seen  troublesome  eruptions,  and  even  ulcerations 
of  the  legs,  from  wearing  stockings  dyed  with  aniline  compounds. 

By  appropriate  treatment  clothing  can  be  made  non-inflammahle. 
Tungstate  and  phosphate  of  soda  are  used  to  reduce  the  inflammabil- 
ity of  fabrics.  The  addition  of  20  per  cent,  of  tungstate  of  soda  and  3 
per  cent,  of  phosphate  of  soda  to  the  starch-sizing  used  for  stiffening 
linen  is  effective.  The  material  is  not  injured  by  it,  and  a  smooth  sur- 
face and  polish  can  be  obtained  under  the  hot  iron.  Prof.  Kedzie 
has  recommended  borax  for  the  same  purpose.  He  says:  "The  sim- 
plest and  easiest  way  to  make  your  cotton  and  linen  fabrics  safe  from 
taking  fire  is  to  dissolve  a  heaped  teaspoonful  of  powdered  borax  in 
one-half  pint  of  starch  solution.  It  does  not  injure  the  fabric,  im- 
parts no  disagreeable  odor,  and  interferes  in  no  way  with  the  subse- 
quent washing  of  the  goods.  It  does  not  prevent  the  formation  of  a 
smooth  and  polished  surface  in  the  process  of  ironing.  Borax  can  be 
found  in  every  village,  and  is  within  the  reach  of  all.  It  is  a  cheap 
salt,  and  its  use  for  this  purpose  is  very  simple."'^ 


"  See  a  practical  paper  by  Dr.  Ben  j.  Lee,  A  Shoe  That  Will  Not  Pinch, 
in  Ran  Italian   for  June,   1884,  p.   49.3. 

''Michigan   State  Board  of  Health,  p.   LSI,   1880. 


366  TEXT-BOOK  OF  HYGIENE. 

RECREATION  AND  REST 

Eecreation  is  not  by  any  means  idleness,  but  a  variety  of  occu- 
pation, and  oftentimes  is  hard  physical  work.  By  its  means  a  relaxa- 
tion of  both  mind  and  body  from  the  worries  and  fatigues  of  one's 
daily  avocation  may  be  effected.  No  rule  can  be  laid  down  as  to  the 
exact  amount  of  sleep  necessary,  for  it  is  a  matter  of  habit,  age,  and 
temperament.  Generally  speaking,  young  persons  require  more  sleep 
than  the  aged.  The  most  refreshing  sleep  is  supposed  to  be  that  taken 
during  the  early  hours  of  the  night,  but  the  habit,  where  necessary, 
of  sleeping  any  time  during  the  twenty-four  hours  may  be  acquired. 
The  following  simple  rules   should  be  observed : — 

Do  not  eat  heavy  meals  late  at  night.  Have  fresh  air  in  the 
sleeping-room  the  year  round,  but  do  not  have  the  bed  in  a  draught. 
Do  not  sleep  with  an  artificial  light  burning  in  the  room;  it  requires 
increased  provision  for  ventilation,  and,  by  shining  in  the  eyes,  pro- 
duces inflammatory  troubles  of  the  lids.  Do  not  have  carpets  or 
hangings  in  the  sleeping-room,  but  let  the  furniture  be  of  the  very 
simplest  kind.  If  two  people  occupy  the  same  room,  they  should  oc- 
cupy separate  beds.  Do  not  sleep  in  any  garments  worn  during  the 
day.  Have  the  night-garments  loose  and  comfortable:  warm  in 
winter,  cool  in  summer.  Have  the  bed-coverings  light  but  warm, 
remembering  that  a  number  of  layers  makes  a  warmer  covering  than 
the  same  weight  of  material  woven  in  one  piece.  Do  not  sleep  on 
feather  beds.  Sleep  with  the  head  low  and  not  with  it  propped  up 
on  several  pillows,  because  this  interferes  with  deep  breathing,  con- 
tracts the  chest,  and  favors  stoop  shoulders.  Lie  on  the  right  side 
when  you  first  go  to  bed ;  it  hastens  food  which  may  be  in  the  stom- 
ach towards  the  pylorus  and  aids  digestion,  favoring  natural  sleep. 


QUESTIONS  TO  CHAPTER  XIII. 

EXERCISE  AND  TRAINING. 

What  is  absolutely  necessary  for  the  maintenance  of  the  healthy  func- 
tions of  the  body?  What  is  the  efTect  of  disuse  upon  any  organ?  Of  train- 
ing? 

What  occurs  when  a  muscle  contracts?  What  is  the  result  of  increased 
activity  of  circulation  in  a  muscle?  What  is  the  effect  of  muscular  action 
on  the  respiratory  process?  What  is  the  difference  as  to  the  absorption  of 
oxygen  in  a  state  of  rest  and  during  work?  As  to  the  elimination  of  carbon 
dioxide  and  water?  What  is  the  effect  of  muscular  action  upon  the  circu- 
lation?    Upon  the  cutaneous  transpiration? 

What  is  the  effect  of  systematic  training  upon  health  and  longevity? 
What  are  some  of  the  principal  and  best  methods  of  physical  training?  What 
is  one  of  its  most  important  objects?  How  may  the  various  methods  be  com- 
bined with  benefit? 

What  should  be  included  among  the  studies  and  work  of  all  public 
schools?  For  what  purposes?  What  is  the  tendency  among  instructors  in 
physical  training?     Is  this  necessary,  or  not?     Why? 

What  is  an  important  preliminary  to  all  methods  of  training?  Why? 
How  may  a  pupil  be  taught  to  assume  and  maintain  a  correct  position  and 
carriage  of  the  body? 

How  should  a  person  walk?  What  attention  should  be  given  to  the 
clothing  worn  during  exercise?  What  will  be  some  of  the  results  of  sys- 
tematic physical  training  properly  pursued? 

What  are  some  of  the  results  of  overexertion?  Does  it  make  a  difference 
whether  the  exercise  is  too  long  uninterrupted  or  whether  it  is  excessive  in 
amount  and  character? 

BATHS  AND  BATHING. 

What  is  the  most  important  object  of  bathing?  For  what  other  pur- 
poses may  baths  be  taken?  What  are  the  respective  temperatures  of  so-called 
cold,  tepid,  warm,  and  hot  baths?  What  are  the  physiological  effects  of  the 
last  three?  In  what  surgical  emergencies  may  the  hot  bath  be  used?  For 
what  are  cold  baths  used?  What  are  their  physiological  effects?  How  m^y 
the  cold  bath  be  used  therapeutically? 

What  is  the  most  stimulating  form  of  cold  bath?  To  what  are  its 
beneficial  effects  due?  How  may  a  salt-water  bath  be  prepared  at  home? 
Is  there  any  danger  to  the  healthy  in  cold  bathing  while  the  body  is  per- 
spiring freely?  What  precaution  should  be  taken  before  entering  a  cold 
bath?  What  rules  may  be  laid  down  for  bathing  in  the  open  air?  When 
is  the  best  time  for  bathing?  Who  should  not  bathe  without  previous  medical 
advice?    When  should  hot  baths  not  be  taken?     What  should  follow  all  baths? 

(367) 


368  TEXT-BOOK  OF  HYGIENE. 

What  is  one  of  the  most  serious  dangers  of  cold  bathing?  How  does 
death  take  place  in  drowning?  What  is  the  indication  that  one  apparently 
drowned  may  still  be  restored  to  life?  Describe  Sylvester's  method  of  arti- 
ficial respiration.  What  is  the  method  adopted  by  the  United  States  Life- 
Saving  Service?  W^iat  is  essential  after  breathing  has  been  re-established? 
How  should  spirits  be  given?  How  long  should  efforts  to  restore  respiration 
be  continued?     What  is  to  be  avoided? 

What  are  some  of  the  arguments  in  favor  of  public  baths  in  large 
cities  ? 

What  is  the  most  economical   form  of  bath   for  public  use? 

CLOTHING. 

What  is  the  primary  object  of  clothing?  What  are  some  of  the  sec- 
ondary objects?  What  are  the  probable  results  of  exposing  the  unprotected 
body  to  low  temperature?  What  part  of  the  body  needs  special  protection 
against  heat? 

What  are  the  principal  materials  from  which  clothing  is  made?  Which 
of  these  is  most  universally  used?  Why?  In  what  respect  is  linen  superior 
to  cotton?  Why  are  cotton  and  linen  not  suited  for  winter  wear  or  cold 
climates?  Why  are  silk  and  wool  better  for  such  uses?  Why  should  wool 
be  worn  next  the  skin?  \Miat  gives  silk  its  value?  Why  are  furs  so  warm? 
What  are  some  of  the  objections  to  the  use  of  rubber  clothing?  For  what 
is  leather  chiefly  used? 

Of  what  importance  is  the  color  of  the  clothing?  What  colors  absorb 
least  and  what  ones  most  heat?  If  protected  from  the  sun's  rays,  which  is 
the  most  important  in  the  absorption  of  heat,  material  or  color? 

What  deleterious  or  harmful  matters  are  absorbed  or  cling  to  clothing? 
What  kinds  of  clothing  have  the  greatest  power  of  absorption?  What  pre- 
cautions should  those  attending  cases  of  infectious  diseases  observe? 

Why  should  clothing  fit  properly?  What  parts  of  the  clothing  should 
not  be  too  tight?  What  disturbances  may  result  from  the  wearing  of  cloth- 
ing that  is  too  tight?  How  may  improperly-dyed  clothing  create  trouble? 
How  may  clothing  be   rendered   practically  non-inflammable? 


CHAPTER  XIV. 

DISPOSAL  OF  THE  DEAD. 

When  life  is  extinct  in  the  animal  body  decomposition  begins. 
This  may  be  either  putrefactive  or  non-putrefactive.  The  difference 
between  the  two  processes  has  been  explained  by  Liebig.  In  putre- 
faction of  organic  matters  only  the  elements  of  water  take  part  in 
the  formation  of  the  new  compounds  which  result,  while  in  non- 
putrefactive  decomposition  or  decay  the  oxygen  of  the  air  always  plays 
an  important  part.  Putrefaction  can  go  on  under  water,  while  decay 
can  only  take  place  when  the  supply  of  free  oxygen  is  abundant. 

The  prompt  removal  of  the  bodies  of  the  dead  from  the  imme- 
diate vicinity  of  the  living  is  a  matter  of  prime  sanitary  importance. 
If  death  results  from  a  contagious  or  an  infectious  disease,  the  neces- 
sity for  the  removal  of  the  corpse  is  evident.  But,  even  where  there 
is  no  danger  of  propagation  of  infectious  disease,  the  products  of 
putrefaction  and  decay  may  give  rise  to  serious  derangements  of 
health  if  allowed  to  pollute  the  air. 

The  chief  methods  of  disposal  of  the  dead  are  burial  in  the  earth, 
entombment  in  vaults,  and  cremation. 

INTERMENT. 

The  most  common  method  of  sepulture  is  burial  in  the  earth. 
The  corpse  is  usually  inclosed  in  a  case  (coffin)  of  wood  or  metal,  and 
buried  from  1  to  3  metres  deep.  Here  decomposition  sets  in,  which  is 
at  first  putrefactive  and  later  on  non-putrefactive.  In  the  course  of 
several  years,  from  five  to  ten,  the  entire  body,  with  the  exception  of 
the  bones,  has  usually  disappeared  and  become  converted  into  a  dry 
mold. 

The  soil  of  a  burial-ground  should  be  dry  and  porous,  so  as  to 
be  easily  permeated  by  the  air.  In  a  sandy  or  gravelly  soil  the  decay 
of  a  corpse  is  much  more  rapid  than  in  a  moist,  clayey  soil.  In  the 
latter  the  bodies  more  readily  undergo  putrefaction,  or  become  con- 
verted into  a  sul)stanee  termed  adipocere.  It  has  been  calculated 
that  in  a  gravelly  soil  the  decay  of  a  corpse  advances  as  much  in  one 
year  as  it  would  in  sand  in  one  and  two-thirds,  and  in  clay  in  two  and 
ono-tbird  years.  The  decay  of  the  dead  bodies  is  dependent  upon  the 
presence  of  living  vegetable  organisms.     If  the  access  of  free  oxygen 

24  (369) 


370  TEXT-BOOK  OF  HYGIENE. 

is  prevented,  the  bacteria  of  putrefaction  will  thrive  and  cause  pu- 
tridity. If,  however,  the  soil  is  loose,  porous,  and  easily  permeable 
by  the  air,  the  bacteria  of  decay  will  be  present  and  produce  their 
characteristic  effects. 

The  barometric  pressure  seems  to  affect  the  decomposition  of 
dead  bodies.  For  example,  at  the  refuge  of  St.  Bernard,  in  the  high 
Alps,  the  bodies  of  those  dying  are  not  buried,  but  exposed  to  the  air, 
where  they  undergo  a  drying,  shrinking,  and  mummification  instead 
of  putrefaction  or  decay. 

Alternate  saturation  and  drying  of  the  soil  promotes  the  rapidity 
of  decay. 

Certain  occupations  are  said  to  produce  changes  in  the  tissues 
which  resist  decay.  Thus,  tanners  are  supposed  to  resist  the  final 
changes  of  the  tissues  longer  than  persons  of  other  occupations. 
Shakespeare  makes  the  grave-digger  in  Hamlet  say:  "A  tanner  will 
last  you  nine  years.''  The  corpses  of  those  poisoned  by  phosphorus, 
arsenic,  sulphuric  acid,  or  corrosive  sublimate  also  decay  more  slowly 
than  in  cases  of  infectious  diseases. 

All  the  tissues  may  be  converted  into  adipocere,  but  in  the  large 
majority  of  cases  only  the  fat  and  connective-tissues  undergo  this 
change. 

SUPPOSED   DANGERS   OF   BURIAL=GROUNDS. 

Popular  sanitary  literature  teems  with  supposed  instances  of  the 
injurious  influences  of  cemeteries  upon  the  health  of  persons  living 
in  their  vicinity.  An  unprejudiced  consideration  of  the  subject  shows,, 
however,  that  there  is  no  trustworthy  evidence  that  any  of  the  gases 
exhaled  by  decaying  or  putrefying  bodies  are  injurious  to  health.  The 
air  of  closed  burial-vaults  may  be  dangerous  from  the  large  proportion 
of  carbon  dioxide  contained  in  it,  but  the  other  gaseous  products  of 
decomposition  have  no  deleterious  effects.  The  dangers  to  health 
from  the  proximity  of  cemeteries  are  doubtless  very  much  exagger- 
ated. Pettenkofer  and  Erismann  have  shovrn  that  a  single  large  privy- 
vault,  containing  about  17  cubic  metres  of  excrement,  gives  off  nearly 
as  large  an  amount  of  putrefactive  gases  in  the  course  of  one  year  as 
is  exhaled  by  a  burial-ground  containing  556  decomposing  corpses 
in  ten  years. 

Where  bodies  are  properly  buried,  and  the  ground  is  not  over- 
charged by  corpses,  it  is  not  probable  that  infectious  diseases  are  pro- 
pagated from  interred  bodies.  There  are  no  facts  on  record  which 
show  that  such  an  event  has  occurred. 


CREMATION.  371 

The  dangers  of  pollution  of  water  by  cemeteries  have  also  been 
much  overestimated.  The  purifying  power  of  soil  strata,  through 
which  the  water  is  compelled  to  percolate  before  reaching  the  well 
after  becoming  charged  with  the  products  of  decomposition,  is  in 
most  cases  sufficient  to  remove  all  deleterious  matters.  It  must  be 
admitted,  however,  that  it  is  not  desirable  to  have  a  well  or  other 
source  of  water-supply  in  close  proximity  to  a  burial-ground. 

Cemeteries  should  not  be  located  within  a  city,  but  must  be  easily 
accessible.  The  soil  should  be  dry  gravel  or  sand,  with  a  low  ground- 
water level.  The  graves  need  not  be  deeper  than  II/2  metres  to  the 
top  of  the  coffin. 

ENTOMBMENT   IN   VAULTS. 

Burial-vaults  in  churches  or  in  the  open  air  should  be  discoun- 
tenanced. The  gases  of  decomposition  are  given  off  directly  to  the 
air  without  the  modifying  power  of  the  soil,  and  often  constitute  a 
nuisance,  even  if  not  deleterious  to  health.  Entombment  in  vaults 
or  crypts  has  not  a  single  favorable  circumstance  to  recommend  it. 

CREMATION. 

Within  recent  years  the  rapid  incineration  of  the  dead  in 
properly-constructed  furnaces  has  been  frequently  recommended.  In 
the  United  States  a  cremation  furnace  was  built  years  ago  at  Washing- 
ton, Pa.,  by  the  late  Dr.  J.  C.  LeMoine.  Among  the  remains  of  those 
cremated  were  those  of  the  late  Dr.  Samuel  D.  Gross,  the  distin- 
guished surgeon.  The  practice  has  not  gained  very  many  adherents. 
hoAvever,  although  cremation  societies  have  been  organized  and  fur- 
naces built  in  several  of  the  cities  throughout  the  country.  Aside 
from  the  objections  urged  by  the  more  conservative  classes,  who  de- 
sire to  adhere  to  the  time-honored  custom  of  interment,  serious  legal 
objections  have  been  brought  forward.  In  cases  where  poisoning  is 
suspected  some  time  after  death,  the  cremation  furnace  would  have 
destroyed  every  evidence  of  crime,  and  conviction  of  a  criminal 
poisoner  could  not  be  obtained. 

The  real  advantages  of  cremation,  such  as  rapid  destruction  of 
a  corpse,  economy  of  space  in  keeping  the  remains,  and  avoidance  of 
pollution  of  the  soil  by  decaying  bodies,  and  possible  pollution  of 
air  and  water,  are  more  than  counterbalanced  by  the  expense  and  the 
medico-legal  objection  mentioned.  From  a  sanitary  point  of  view, 
cremation  is  not  necessary  in  this  country.  A  proper  regulation  of 
cemeteries  will  prevent  any  possible  dangers  to  the  living  from  pollu- 
tion of  the  ail',  soil,  or  water  by  the  decaying  remains  of  human  beings. 


372  TEXT-BOOK  OF  HYGIENE. 

INTERMENT  ON  THE  BATTLE=FIELD. 

After  battles,  the  disposal  of  the  bodies  of  the  slain  is  often  a 
serious  problem.  Naegeli  proposes  the  following  method  of  inter- 
ment :  After  selecting  the  place  of  burial,  the  sod  and  la3^er  of  humus 
are  removed  from  a  sufficiently  large  surface  and  thrown  to  one  side. 
The  corpses  are  then  laid  upon  the  denuded  place,  and  the  layers  of 
corpses  separated  by  sand,  gravel,  or  fine  brush-wood.  A  trench  is 
then  dug  around  the  pile  of  dead  and  the  soil  gained  is  thrown  over 
the  corpses  until  they  are  covered  to  a  depth  of  1  metre,  when  the 
humus  and  sod  are  placed  over  the  whole.  This  furnishes  a  dry 
grave  in  which  decay  rapidly  takes  the  place  of  putrefaction,  and  the 
corpses  soon  molder  away.  The  same  procedure  may  be  followed  in 
cases  of  epidemics  where  the  number  of  deaths  is  too  great  to  prop- 
erly bury  them  in  single  graves. 

Before  leaving  this  subject  it  may  be  well  to  consider  the  matter 
of  funerals.  The  pernicious  custom  of  public  funerals  in  cases  of 
contagious  diseases  cannot  be  too  strongly  condemned.  In  fact,  pub- 
lic funerals  in  such  cases  should  not  be  permitted  by  the  health  au- 
thorities. To  minimize  the  danger,  the  bodies  of  persons  dead  of  con- 
tagious diseases  should  be  wrapped  in  sheets  wet  with  a  solution  of 
bichloride  of  mercury  (1:500),  and  the  coffin  kept  securely  closed. 
Still  more  pernicious  is  the  custom  of  disposing  of  the  clothing  and 
other  personal  property  of  the  dead  of  contagious  diseases  by  either 
distributing  them  among  friends,  donating  to  the  poor,  or  selling  to 
second-hand  dealers.  Many  epidemics  of  contagious -diseases  have 
had  their  origin  in  this  way.  There  should  be  a  strict  law  prohibit- 
ing the  sale  of  any  article  with  which  the  deceased  has  come  in  con- 
tact during  the  last  illness,  unless  such  article  is  thoroughly  disin- 
fected. 


QUESTIONS  TO  CHAPTER  XIV. 

DISPOSAL  OF  THE  DEAD. 

What  is  the  difference  between  putrefactive  and  non- putrefactive  decom- 
position? Why  must  the  dead  be  removed  from  the  living?  What  are  the 
chief  methods  of  disposal  of  the  dead?     Which  is  the  most  common? 

Why  should  the  soil  of  burial-grounds  be  dry  and  porous?  Upon  v/hat 
is  the  decay  of  dead  bodies  dependent?  What  is  the  usual  length  of  time  re- 
quired for  the  decay  of  a  human  body?  What  may  affect  the  length  of  this 
period?     What  changes  other  than  decay  may  the  body  undergo? 

Is  there  any  evidence  that  the  air  from  cemeteries  is  dangerous  to 
health?  In  what  way  may  the  air  from  a  closed  burial-vault  be  detrimental? 
Is  it  probable  that  infectious  disease-germs  are  disseminated  from  dead  bodies  ? 
Is  the  pollution  of  water  by  cemeteries  probable?  What  agents  serve  to  pre- 
vent this?  Where  should  cemeteries  be  located,  however?  Why  should  en- 
tombment in  vaults  be  discountenanced? 

What  are  the  advantages  of  cremation?  What  are  the  objections  to 
it?     Is  it  necessary,  from  a  sanitary  point  of  view,  in  this  cormtry? 

How  may  the  bodies  of  the  dead  be  interred  after  battles,  or  in  case  of 
very  fatal  epidemics?     What  are  the  advantages  of  this  method? 

What  precautions   should  be  observed  in  cases   of  contagious   diseases? 


(373) 


CHAPTER  XV. 

THE  GERM  THEORY  OF  DISEASE. 

The  ruling  doctrine  in  tlie  pathology  of  the  jDresent  clay  is  the 
germ  theory  of  disease.  Based  upon  the  doctrine  of  omne  vivuni  ex 
vivo,  and  supported  by  strong  experimental  and  clinical  evidence,  it 
is  accepted  by  the  great  majority  of  physicians.  Its  advocates  claim 
that  the  large  class  of  diseases  known  as  contagious  or  infectious  are 
all  due  to  the  presence  in  the  blood  or  tissues  of  minute  organisms, 
either  animal  or  vegetable.  Many  other  diseases,  not  at  present  in- 
cluded in  the  above  class  by  general  pathologists,  are  also  believed,  by 
the  adherents  of  the  germ  theory,  to  be  caused  in  the  same  Avay, 
The  following  constitutes  a  brief  review  of  the  most  prominent  facts 
in  the  history  of  the  doctrine: — 

The  doctrine  of  the  vital  nature  of  the  contagion  of  disease — 
the  contagium  animatum  of  the  older  writers —  was  held  in  a  vague 
way  by  many  of  the  physicians  of  the  past,  but  it  was  not  until  the 
latter  part  of  the  last  century  that  the  theory  took  definite  shape. 
In  the  works  of  Hufeland,  Kircher,  and  Linne,  the  idea  is  expressed 
with  more  or  less  directness  that  the  propagation  of  infectious  dis- 
eases depends  upon  the  implantation  of  minute  independent  organ- 
isms into  or  upon  the  affected  individual.  This  hypothesis  was,  how- 
ever, first  clearl}^  enunciated  and  defended  with  great  force  by  Henle 
in  1840.  Three  years  earlier,  Cagniard  de  la  Tour  and  Schwann  had 
established  a  rational  basis  for  the  theory  by  their  observations  upon 
the  3^east-plant  and  its  relation  to  fermentation.  In  1835  Bassi  had 
discovered  in  the  bodies  of  silk-worms  affected  by  muscardine,  a  dis- 
ease of  these  insects  which  proved  very  destructive,  a  parasite  which 
was  soon  shown  to  be  the  cause  of  the  disease.  Within  the  next  few 
years,  Tulasne,  DeBarry,  and  Kuehn  proved  that  certain  fungi  were 
the  causes  of  the  potato-rot  and  other  diseases  of  plants.  Schoenlein, 
Malmsten,  and  Gruby,  between  1840  and  1845,  demonstrated  that 
those  skin  diseases  of  man  classed  as  the  tinece  were  due  entirely  to 
the  action  of  vegetable  parasitic  organisms. 

Up  to  this  time  the  germ  theory,  as  now  accepted,  had  received 
no  support  from  experiments.  All  the  diseases  claimed  as  parasitic 
were  purely  local ;  so  far  as  the  parasitic  nature  of  the  general  dis- 
eases was  concerned,  all  was  hypothetical.  In  1849,  Guerin  Meneville 
(374) 


THE  GERM  THEORY  OF  DISEASE. 


375 


discovered  a  corpuscular  organism  in  the  blood  of  silk-worms  affected 
by  the  pehrine,  which  was  later  proven  by  Pasteur  to  be  the  true  cause 
of  this  destructive  disease.  Pollender,  in  1855,  and  Brauell,  in  1857, 
found  numerous  minute  rod-like  organisms  (bacteria)  in  the  blood 
of  animals  dead  from  splenic  fever  or  anthrax.  In  1863  Davaine  in- 
vestigated the  subject  more  fully,  and  showed  beyond  doubt  that  the 
little  organisms  discovered  by  Pollender  were  the  true  cause  of  an- 
thrax. The  more  recent  researches  of  Eobert  Koch  upon  the  history 
of  these  bacteria  or  bacilli  of  splenic  fever  have  removed  all  doubt 
of  their  etiological  significance. 


Sarcina  (Packet-cocci) 


Cocci 


With 
capsules 


Staphylococci 


Streptococci 


Diplococci 


Tetracocci 


Ciliated  cell  -^  . ' 


Spider  cell 
Diplococciis 


Tetracoccus  a  >a       /-^/^  (. 


Monococcus 

Centrally  situated 
spores 
Clostridia  forms 
Knobbed  bacteria  with 
tenninal  spores 


/ 


*w\^ 


.i|4  Zoogloea 

m 


Slender  bacilli 
Short  bacilli 
Bacilli  in  chains 
Vibrios  (spirilla^ 

Comma  bacilli 
Spirochaetse 


Pig.  43. — Forms  of  Bacteria.      (From  Schenk. ) 

In  1883  the  last-named  observer  startled  the  medical  world  by 
the  assertion  that  consuinption  or  tuberculosis  was  a  disease  of 
microbic   origin,  and   dependent  upon   the  presence,  in  the  affected 


376  TEXT-BOOK  OF  HYGIENE. 

tissues^  of  an  organism  which  he  named  Bacillus  tuberculosis.  Much 
controversy  arose  upon  this  point,  but  Koch  fortified  his  position  so 
strongly  with  proofs,  both  exp.erimental  and  clinical,  that  it  may  now 
be  regarded  as  fully  demonstrated.  Koch  has  likewise  shown  (1885) 
that  Asiatic  cholera  is  due  to  a  bacterial  organism,  termed  by  him 
the  "comma  bacillus,"  from  its  shape.  It  is  generally  regarded  by 
bacteriologists,  however,  to  belong  to  the  class  of  organisms  known  as 
spirilla,  and  not  to  the  bacilli.  Eberth  discovered  the  bacillus  which 
is  now  generally  accepted  as  the  cause  of  typhoid,  in  1880 ;  Fehleisen, 
the  micrococcus  of  erysipelas,  in  1883 ;  Obermeier,  the  spirillum  of 
relapsing  fever,  in  1868;  Schutz  and  Loffler  discovered  the  bacillus 
of  glanders  in  1882;  I^eisser  announced  the  discovery  of  the  micro- 
coccus of  gonorrhea  in  1879.  The  bacillus  of  leprosy  was  discovered 
by,  Hansen,  in  1879.  The  micro-organism  of  malaria  (plasmodium 
malarije),  which  is  an  animal  organism,  was  discovered  by  Laveran. 
in  1881.  This  organism  is  different  from  the  Bacillus  malarice  of 
Klebs  and  Tommasi-Crudeli,  which  possesses  no  pathological  signifi- 
cance. Pneumonia  may  also  be  regarded  as  a  microbic  disease,  since 
Sternberg^  Weichselbaum,  and  Frankel  have  shown  the  constant  pres- 
ence of  the  diplococcus  lanceolatus  in  the  sputa  in  that  disease.  In 
1884,  Nicolaier  and  Eosenbach  proved  that  tetanus  is  due  to  a  bacil- 
lus. Bacillus  tetani.  In  the  same  year  Loffler  isolated  the  diphtheria 
bacillus,  observed  previously  by  Klebs.  In  1892,  Cauon  and  Pfeiffer 
discovered  the  bacillus  of  influenza,  and  in  1891,  Ycrzin  and  Kitasato 
independently  isolated  the  bacillus  of  bubonic  plague. 

The  careful  observations  and  researches  of  the  investigators 
mentioned,  as  well  as  of  many  others  who  have  worked  earnestly  in 
this  field,  have  established  the  germ  theory  of  disease  upon  a  secure 
foundation.  For  the  diseases  mentioned  the  parasitic  origin  may  be 
accepted  as  fully  proven.  For  a  number  of  others,  among  which  may 
be  mentioned  small-pox,  yellow  fever,  scarlet  fever,  typhus  fever, 
measles,  hydrophobia,  etc.,  the  etiological  connection  between  the  dis- 
ease and  certain  hypothetical  organisms  not  yet  discovered  appears 
highly  probable. 

In  connection  with  the  germ  theor}'-  there  has  arisen  of  late  a 
very  important  question  in  its  bearing  upon  preventive  medicine. 
This  is  the  value  of  the  so-called  protective  inoculations  against  in- 
fectious diseases.  The  protective  influence  of  vaccination  against 
small-pox  is  firmly  established  by  indubitable  evidence.  Within  re- 
cent years  a  procedure  introduced  by  Pasteur  to  protect  animals 
against  certain  fatal  infectious  diseases,  such  as  splenic  fever,  fowl- 


THE  GERM  THEORY  OF  DISEASE.  377 

cholera,  and  rabies,  has  claimed  much  attention.  Pasteur's  observa- 
tions were  first  made  upon  the  disease  termed  chicken-cholera.  He 
found  that  the  blood  of  the  dead  fowls,  or  of  those  attacked  by  the 
disease,  swarmed  with  bacteria.  Inoculations  of  healthy  fowls  with 
this  diseased  blood,  or  with  the  bacteria  alone,  carefully  freed  from 
all  animal  fluids,  produced  the  same  disease.  The  bacteria  were  there- 
fore assumed  to  be  the  cause  of  the  disease.  The  investigator  then 
took  a  quantity  of  these  bacteria  and  '^'cultivated"  them  through  a 
number  of  generations,  using  sterilized  chicken-broth  as  a  culture 
medium.  Fowls  inoculated  with  the  result  of  the  last  cultivation  were 
'still  attacked  by  the  same  symptoms,  but  in  a  very  mi'd  degree,  and 
almost  uniformly  recovered  from  the  disease.  On  subsequent  inocu- 
lation with  infected  blood  no  effect  was  produced  upon  the  '"Vaccin- 
ated" fowls,  while  the  same  blood  introduced  into  fowls  not  "pro- 
tected" by  the  previous  inoculation  produced  its  customary  fatal  effect. 
Pasteur  and  others  repeated  these  experiments  with  the  organisms 
found  in  the  blood  in  splenic  fever  and  obtained  similar  results.  In- 
oculations made  with  emulsions  from  the  desiccated  spinal  cords  of 
animals  that  died  from  rabies  have  also  proven  protective  against  this 
disease.  These  protective  inoculations  have  been  made  upon  large 
numbers  of  sheep,  cattle,  and  man,  with  very  remarkable  success.  The 
"protective  inoculations"  produce  an  immunity  which  is  more  oi  less 
lasting. 

The  most  important  discovery  along  the  lines  of  immunity  was 
made  by  Behring,  in  1893.  This  observer  found  that  if  diphtheria 
bacilli  are  cultivated  in  bouillon  for  about  a  week,  the  medium  con- 
tains the  toxic  substances  of  the  bacilli  in  solution.  The  bacilli  may 
then  be  entirely  removed  by  filtration  and  the  clear  fluid  represents 
the  toxin,  of  which  about  0.001  cubic  centimetres  will  kill  a  guinea- 
pig  weighing  250  to  300  grams.  If  this  toxin  is  injected  into  an 
animal  in  gradually  increasing  doses,  neither  of  which  ig  large  enough 
to  prove  fatal,  the  animal  acquires  an  immunity  to  the  diphtheria 
toxins,  which  are  the  products  of  the  diphtheria  bacillus.  Now,  the 
blood-serum  of  this  immunized  animal  is  capable  of  neutralizing  the 
toxic  properties  of  the  diphtheria  toxin  either  in  the  test-tube  or  in 
the  body  of  another  animal ;  in  other  words,  the  blood-serum  con- 
tains antitoxins. 

For  practical  purposes,  a  healthy  horse  is  injected  with  gradually 
increasing  doses  of  toxin,  beginning  with  0.1  cubic  centimetres  and 
ending  with  several  doses  of  500  cubic  centimetres  each.  At  the  end  of 
about  six  weeks  from  five  to  nine  quarts  (according  to  the  size  of  the 


378  TEXT-BOOK  OF  HYGIENE. 

horse)  of  blood  are  withdrawn  from  the  jugular  vein,  the  blood  al- 
lowed to  coagulate,  and  the  clear  eerum  prepared  for  the  market. 
This  serum  is  the  diphtheria  antitoxin.  This  antitoxin,  when  injected 
into  a  person  suffering  from  diphtheria,  Avill  neutralize  all  of  the 
free  toxins  circulating  in  the  b'.ood,  and  the  outcome  of  the  case  de- 
pends entirely  on  whether,  at  the  time  the  antitoxin  is  used,  the 
toxin  particles  are  mostly  free  or  combined  with  the  tissue  cells.  In 
the  latter  event  the  antitoxin  is  powerless  to  accomplish  very  much, 
and  the  issue  is  fatal.  It  is  for  this  reason  that  the  modern  physi- 
cian emplo3^s  antitoxin  at  the  earliest  possible  stage  of  the  disease,  so 
as  to  neutralize  the  free  toxins  before  they  have  a  chance  to  combine 
with  the  cells.  For  this  reason  also  a  small  dose  of  antitoxin,  when 
injected  into  persons  exposed  to  the  infection,  may  prevent  the  de- 
velopment of  the  disease.  The  introduction  of  antitoxin  in  the  treat- 
ment of  diphtheria  has  reduced  the  mortality  from  diphtheria  from 
50  to  about  10  per  cent. 

Tetanus  antitoxin,  elaborated  by  Behring  and  Kitasato,  in  1890, 
is  based  on  the  same  principles  and  prepared  very  much  in  the  same 
manner,  with  the  exception,  of  course,  that  the  tetanus  bacillus  is 
cultivated  under  anaerobic  conditions.  From  a  therapeutic  stand- 
point, however,  the  antitoxic  serum  is  not  as  useful  as  in  the  case  of 
diphtheria.  The  reason  given  is  that  by  the  time  the  symptoms  of 
tetanus  develop,  the  toxin  is  practically  combined  entirely  with  the 
nerve-cells  and,  therefore,  cannot  be  neutralized.  On  the  other  hand, 
when  the  antitoxin  is  used  at  the  time  the  invasion  of  the  bacillus 
occurs,  or  during  the  period  of  incubation,  the  development  of  the 
disease  may  be  prevented  with  absolute  certainty.  It  is  this  fact  that 
led  veterinarians  to  use  tetanus  antitoxin  in  every  case  of  suspicious 
wound  in  a  horse,  a  practice  which  should  be  followed  by  the  physi- 
cian in  case  of  any  suspicious  wound  in  man. 

The  immunity  conferred  by  the  use  of  antitoxins  is  passive  and 
temporary,  the  body  of  the  patient  not  participating  in  its  production. 
In  the  case  of  other  infections  which  are  caused  by  micro-organisms 
not  possessing  soluble  toxin,  the  immunization  must  be  active,  and 
can  only  be  accomplished  artificially  by  the  employment  of  "vaccines" 
prepared  from  the  bodies  of  the  dead  germs.  This  form  of  immu- 
nity, which  may  be  cal'ed  "bacterial,"  depends  for  its  production  on 
altogether  different  forces,  namely,  the  property  of  the  white  blood- 
cells  to  attract  and  devour  bacteria,  or,  as  MetchnikofP  termed  it, 
"phagocytosis."  However,  before  invading  micro-organisms  can  be 
imbibed  by  the  phagocytes  they  must  be  acted  upon  or  prepared  by 


THEORIES  OF  IMMUNITY.  379 

another  substance  which  is  present  in  the  blood.  This  substance, 
whatever  its  nature,  renders  the  bacteria  capable  of  becoming  im- 
bibed by  the  phagocytes,  and  has  been  recently  designated  by  Wright 
and  Douglas  as  "opsonins"  (from  opsono,  I  prepare  food  for).  The 
relative  power  of  phagocytosis  in  the  blood  of  a  patient  suffering 
from  an  infection,  as  compared  with  the  phagocytic  power  of  the 
blood  of  a  healthy  individual  towards  the  same  germ,  is  called  the 
"opsonic  index." 

These,  however,  are  not  the  only  defensive  forces.  There  are  no 
doubt  a  number  of  other  substances  in  the  tissues  and  fluids  of  the 
animal  organisms  which  protect  the  latter  against  disease,  and  it  is 
the  weakening  of  any  or  all  of  them  that  makes  infection  possible. 
The  subject  of  immunity  is  a  very  wide  one,  and  it  is  only  now  that 
we  are  beginning  to  understand  it.  The  time  will  no  doubt  come 
when  every  infectious  disease  will  be  either  prevented  or  cured  by 
stimulating  the  production  of  the  necessary  defensive  agents. 

THEORIES  OF  IMMUNITY. 

No  treatise  on  hygiene  is  complete  without  a  consideration  of 
the  factors  concerned  in  the  protection  of  the  animal  organism 
against  infection,  or  overcoming  infection  already  present.  Broadly 
speaking,  the  natural  tendency  of  the  body  is  to  keep  along  the  line 
of  health.  Any  deviation  from  that  line  is  promptly  met  by  an 
effort  on  the  part  of  the  organism  to  correct  its  course  and  re-estab- 
lish a  healthy  equilibrium.  A  foreign  body  in  the  eye  is  instantly 
flooded  with  tears  in  order  that  it  may  be  washed  out.  Failing  in 
that,  an  inflammatory  reaction  is  set  up,  the  object  being  to  surround 
the  irritant  by  adhesion  and  thus  shut  it  off  from  further  irritation. 
A  fractured  limb  is  immediately  placed  by  Mother  Nature  in  a  state 
of  enforced  rest,  owing  to  the  excruciating  pain  which  the  motion 
of  the  limb  produces,  and  at  first  a  temporary  and  then  a  permanent 
splint  (callus)  are  placed  around  the  fragments,  remaining  there  until 
restoration  of  continuity.  Certain  poisons  which  are  generated  in 
the  course  of  normal  metabolism  are  neutralized  and  eliminated  so 
as  to  prevent  self-poisoning.  A  local  invasion  of  pus-producing  bac- 
teria (staphylococcus,  streptococcus,  etc.)  is  a  signal  for  an  imme- 
diate concentration  of  armies  of  leukocytes  in  an  attempt  to  destroy 
the  invader,  and,  failing  in  that,  an  effectual  barrier  against  further 
invasion  is  formed  through  a  process  of  inflammation  which  results 
in  the  formation  of  a  membrane,  the  so-called  pyogenic  membrane. 
The  invasion  of  bacteria  into  the  general  circulation,  or  the  absorp- 


380  TEXT-BOOK  OF  HYGIENE. 

tion  of  their  products  (toxins),  stimulates  the  production  of  sub- 
stances in  the  body  which  destroy  the  micro-organisms  or  neutralize 
their  poisons.  Thus,  the  natural  forces  of  the  body  are  continuously 
at  work,  maintaining  the  organism  in  a  state  of  health.  When  these 
forces  become  inadequate,  or  are  temporarily  deranged,  disease  or  a 
deviation  from  the  normal  line  results. 

Immunity  may  be  defined  as  a  natural  or  acquired  resistance  to 
disease.  Generally,  the  term  refers  to  infectious  diseases.  Immunity 
may  be  racial,  as  the  immunity  of  the  negro  to  yellow  fever,  or  indi- 
vidual; it  may  be  active,  when  the  result  of  natural  infection  or 
inoculation,  'or  passive,  when  produced  by  the  introduction  of  sub- 
stances derived  from  animals  actively  immunized,  as  in  the  case  of 
antitoxin  treatment.  Immunity,  furthermore,  may  express  itself 
against  the  bacteria  (antibacterial),  the  toxins  (antitoxic),  or  against 
cells  from  an  animal  of  a  different  species  (cytolytic). 

In  order  to  more  fully  appreciate  the  relation  of  the  subject  of 
immunity  to  hygienic  problems,  it  may  be  well  to  consider  briefly 
the  two  factors  involved  in  the  causation  of  infectious  diseases.  These 
are :  the  specific  micro-organism  or  the  exciting  cause,  and  the  resist- 
ance of  the  individual  or  the  predisposing  cause.  The  former  may  be 
likened  to  a  plant-seed,  the  latter  to  the  soil.  Given  a  vigorous  seed 
and  a  poor  soil,  no  growth  will  take  place.  Similarly,  a  favorable 
soil  and  a  poor  seed  will  remain  barren.  To  get  the  best  results,  both 
the  seed  and  the  soil  must  be  in  the  very  best  condition.  This  is 
precisely  the  case  in  infection.  A  virulent  micro-organism  remains 
powerless  in  the  absence  of  a  predisposition,  nor  will  infection  occur 
in  the  presence  of  a  predisposition  with  an  avirulent  micro-organism. 
As  neither  viru^.ence  nor  resistance  are  constant  factors,  the  resulting 
infection  will  vary  in  each  individual  case,  from  a  mild  to  a  fatal 
attack.  The  virulence  of  a  micro-organism,  under  natural  conditions, 
is  increased  by  passage  through  the  bodies  of  susceptible  individuals, 
and  decreased  by  passage  through  the  bodies  of  relatively  insusceptible 
persons.  This  explains  the  rise  and  fall  of  an  epidemic.  At  first, 
the  most  susceptible  individuals  in  a  community  are  attacked.  As 
the  specific  micro-organism  passes  through  the  bodies  of  these  victims 
it  gains  in  virulence,  and  the  epidemic  gains  in  fury  until  the  most 
insusceptible  individuals  are  reached,  when  the  virulence  of  the  micro- 
organism begins  to  decline,  and  the  epidemic  dies  out.  The  virulence 
of  bacteria  may  also  be  influenced  by  climatic  and  atmospheric  con- 
ditions and  by  association  of  two  or  more  species  which  either  in- 
creases or  decreases  the  virulence  of  the  respective  species.    This  asso- 


THEORIES  OF  IMMUNITY.  381 

ciation  is  known  as  symbiosis.  On  the  other  hand,  the  predisposition 
or  susceptibility  of  the  individual  may  be  increased  by  bad  hygienic 
surroundings,  chronic  poisoning,  alcoholism,  fatigue,  and  overwork 
of  the  nervous  system,  exposure  to  cold,  improper  diet,  drugs,  surgical 
operations,  injuries,  previous  disease.  In  preventing  infection,  there- 
fore, we  sliouM  aim  at  a  destruction  of  the  bacteria,  or  at  least  a 
reduction  of  their  virulecce  by  the  use  of  antiseptics,  etc.,  and  at  the 
same  time  we  should  enhance  the  resistance  of  the  individual.  In 
other  words,  we  must  render  the  seed  inactive  and  the  soil  unfavor- 
able. 

The  accepted  theories  of  immunity  are  (1)  Metchnikoff's  theory 
of  phagocytosis  and  (2)  Ehrlich^s  side-chain  theory.  Each  explains 
part  of  the  phenomenon,  and  the  truth  probably  lies  between  the  two. 

(1)  According  to  Metchnikoff  and  his  followers,  certain  cells  in 
the  animal  body  possess,  in  common  with  ameba  and  other  unicellular 
organisms,  the  property  of  incorporating  and  digesting  foreign  sub- 
stances. These  substances  are  attracted  by  the  ce  Is  by  a  bio-physical 
process  known  as  chemiotaxis,  which  may  be  positive  or  negative, 
depending  on  whether  the  foreign  body  is  attracted  or  repelled.  The 
presence  of  the  foreign  body  within  the  cell  stimulates  the  production 
of  cellular  enzymes,  cytases,  wdiich  act  as  digestive  ferments.  The 
entire  process  is  called  phagocytosis,  from  the  Greek  c^aysiv,  to  eat, 
and  *  /euros,  cell.  In  the  human  body,  two  chief  varieties  of  phago- 
cytes are  present:  (a)  The  microphages,  which  are  the  polymorpho- 
nuclear  leukocytes  of  the  blood,  and  (b)  the  macrophages,  which 
include  the  large  mononuclear  leukocytes,  the  fixed  connective  tissue 
cells,  and  other  cells  possessing  phagocytic  properties.  The  micro- 
phages exert  a  special  digestive  action  on  bacteria,  while  the  macro- 
phages possess  special  activity  toward  animal  cells  and  protozoa. 
When  the  digestive  ferment  of  the  microphages,  the  microcytase,  is 
given  off  by  the  cells  and  is  circulating  in  the  blood,  the  blood-serum 
acquires  bacteriolytic  or  cytolytic  properties. 

In  insusceptible  or  immunized  animals  the  specific  bacteria  are 
attracted  by  the  microphages  and  ingested  and  digested.  However, 
before  the  digestion  of  the  bacteria  can  take  place,  they  must  undergo 
certain  alteration,  and  this  is  accomplished  by  a  specific  substance, 
also  the  product  of  the  leukocytes,  called  fixateur,  or  fixative,  which 
corresponds  to  the  "immune-body"  of  the  German  schools,  or  the 
"opsonins"  of  Wright  and  Douglas.  These  opsonins  are  present  in 
the  blood  of  every  individual  to  a  degree  proportionate  to  his  resist- 
ance to  a  given  infection.     When  infection  takes  place,  the  organism 


382  TEXT-BOOK  OP  HYGIENE. 

is  depressed  at  first,  and  the  opsonins  are  diminished,  or  what  is  called 
a  "negative  phase"  takes  place.  As  soon  as  the  organism  recovers 
from  this  primary  depression,  the  opsonins  increase,  and  a  "positive 
phase"  is  reached. 

Briefly  stated,  the  process  of  immunity,  according  to  Metchni- 
koff,  is  as  follows : — 

(a)   The  pathogenic  bacteria  invade  the  body. 

(h)  The  microphages  are  attracted  to  the  bacteria  and  the  latter 
are  fixed  and  ingested. 

(c)  The  presence  of  the  bacteria  stimulates  the  production  of 
cytase,  which  acts  on  the  "sensitized"  bacteria,  resulting  in  a  com- 
plete digestion  of  the  latter  or  bacteriolysis. 

It  will  be  observed  that  while  Metchnikoff's  theory  explains 
immunity  against  the  action  of  bacteria  and  toxic  cells,  it  fails  to 
explain  antitoxic  immunity.  The  latter  is  best  elucidated  by  the 
theory  elaborated  by  Ehrlich  and  his  followers. 

2.  The  Lateral-cliain  Theory. — According  to  this  theory,  the  ani- 
mal cell  is  made  up  of  numerous  bio-chemical  atom-groups,  the  so- 
called  biogen  molecules.  These  groups  possess  specific  affinities  for 
similar  groups  in  either  food  or  other  organic  molecules.  These 
atom-groups  or  side-chains  in  the  cell  are  called  receptors,  while  the 
corresponding  groups  in  the  food-molecule  are  called  haptophores 
(from  the  Greek  airreiv,  to  touch,  and  4*^puv,  to  bring).  In  the  process 
of  nutrition,  the  receptors  unite  with  the  haptophores  of  the  food- 
molecule,  and  thus  the  latter  becomes  an  integral  part  of  the  cell. 
With  food-molecules  of  a  more  complex  composition,  the  process  is 
somewhat  different.  Here  the  food-molecule  cannot  enter  into  com- 
bination with  the  receptor  of  the  cell  unless  it  is  in  some  way  modi- 
fied. This  modification  or  elaboration  of  the  complex  food-molecule 
is  accomplished  by  receptors  possessing  two  different  atom-groups. 
One  atom-group  possesses  an  affinity  for  a  ferment-like  substance 
present  in  the  blood-plasma — complement — which  prepares  the  food- 
molecule,  which  then  combines  with  the  other  atom-group.  Eecep- 
tors  possessing  two  such  atom-groups  are  called  amhoceptors. 

Extending  this  h5q)othesis  to  the  explanation  of  immunity,  we 
assume  that  a  molecule  of  bacterial  toxin  behaves  toward  the  cell  very 
much  like  a  food-molecule,  with  this  difference:  A  toxin  molecule 
possesses  two  atom-groups,  a  haptophorous  group,  which  combines 
with  the  receptors  of  the  cell,  and  a  toxophorous  group,  which  exerts  a 
poisonous  effect  on  the  cell.  If  the  amount  of  toxin  is  not  sufficient 
to  destroy  the  cell,  the  latter  is  stimulated  to  an  over-production  of 


THEORIES  OF  IMMUNITY.  383 

receptors,  which  are  cast  off  and  circulate  freely  in  the  blood.  These 
free  receptors  anchor  the  toxin  molecules  as  soon  as  they  enter  the 
circulation,  and  thus  prevent  their  combining  with  the  cells.  In  this 
manner  antitoxic  immunity  is  established  and  maintained.  In  the 
light  of  this  hypothesis,  antitoxin  is  blood-serum  containing  free 
receptors,  and  by  its  introduction  into  tlie  system  in  cases  of  infec- 
tion (diphtheria,  tetanus)  we  administer  free  receptors,  which  cir- 
culate in  the  blood  and  anchor  the  toxin  molecules,  which  are  thus 
neutralized  before  they  can  combine  with  the  cells.  The  immunity 
produced  by  the  injection  of  antitoxin  is  called  passive,  and  is  espe- 
cially characterized  by  its  short  duration,  contrasting  with  the  lasting 
imimunity  produced  in  the  body  of  an  individual  who  overcomes  suc- 
cessfully the  infection. 

In  the  case  of  the  more  complex  bacterial  bodies  or  toxic  foreign 
cells,  the  amboceptors  are  the  protective  agents.  Here,  while  one 
atom-group  combines  with  the  complement  which  fixes  the  bacteria, 
or  the  cells,  the  other  destroys  them.  As  a  resuH  of  immunization  or 
natural  infection  the  amboceptors  are  produced  in  excess,  ard  the 
free  amboceptors  circulate  in  the  blood,  rendering  it  bactericidal  or 
cytolytic,  as  the  case  may  be. 


QUESTIONS  TO  CHAPTER  XV. 

ft 

THE  GERM  THEORY  OF  DISEASE. 

What  is  meant  by  the  germ  theory  of  disease?  When  did  this  doctrine 
first  take  definite  shape?  When  was  it  first  clearly  enunciated,  and  by 
whom?  What  basis  was  there  then  for  it?  What  subsequent  evidence  soon 
developed  ?  What  was  the  first  evidence  of  the  parasitic  nature  of  general 
diseases?  Who  discovered  and  who  first  demonstrated  the  true  cause  of 
anthrax?  Who  proved  tuberculosis  to  be  of  microbic  origin?  When?  What 
other  diseases  are  now  known  to  be  caused  by  specific  micro-organisms? 
What  others  are  probably  due  to  a  like  cause? 

What  eflfeet  has  the  establishing  of  the  germ  theory  upon  preventive 
medicine?  What  is  meant  by  protective  inoculation?  What  evidence  is  there 
that  this  is  possible?  How  do  disease  germs  produce  their  characteristic 
effects  upon  the  system?  How  may  the  inoculating  material  be  prepared? 
How  is  diphtheria  antitoxin  prepared?  How  do  antitoxins  act?  What  are 
"opsonins"?     What  is  the  "opsonic  index"? 

Define  immunity.  Name  varieties  of  immunity.  What  factors  are  re- 
quisite to  the  production  of  an  infectious  disease?  How  is  the  virulence  of  a 
micro-organism  increased?  How  may  the  resistance  of  the  individual  be 
diminished?  How  may  infection  be  prevented?  Name  the  accepted  theories 
of  immunity.  Describe  Metchnikoff"s  theory.  Define  cytases,  microphages, 
macrophages;  what  are  their  respective  functions?  WTiat  are  receptors?  How 
is  nutrition  of  the  cell  brought  about?  How  do  toxins  combine  with  the  cell? 
What  is  the  function  of  amboceptors?  What  role  do  the  receptors  play  in 
immunity?  Wliat  is  the  difference  in  the  mode  of  action  of  receptors  and 
amboceptors  ? 


(384) 


CHAPTER  XVI. 

CONTAGION  AND  INFECTION. 

The  adjectives  "contagious"  and  "infectious"  are  used  to  desig- 
nate certain  diseases  which  are  propagated  by  immediate  contact,  or 
through  the  intervention  of  some  other  medium,  from  the  sick  to 
the  healthy.  The  matters  in  which  reside  the  morbific  power  are 
micro-organisms. 

The  differentiation  between  contagion  and  infection  is  not  easy. 
Many  of  the  diseases  commonly  called  contagious  are  also  infectious; 
that  is,  they  are  propagated  not  merely  by  direct  contact,  but  also 
by  air,  water,  or  food  which  may  have  become  infected  with  the  mor- 
bific agent.  Syphilis,  for  example,  may  be  regarded  as  simply  a  con- 
tagious disease;  at  the  present  day,  at  least,  we  cannot  conceive  of 
syphilis  to  be  propagated  by  breathing  infected  air  or  drinking  water 
contaminated  with  the  poison  of  syphilis.  Cholera  and  typhoid  fever, 
on  the  other  hand,  are  examples  of  infectious  diseases,  neither  of 
them  being  directly  contagious,  but  conveyed  from  sick  to  well  through 
the  medium  of  contaminated  water,  or  food.  Between  these  two  stand 
small-pox  and  typhus  fever  (and  perhaps  the  other  exanthemata), 
which  are  not  merely  contagious,  but  infectious  also. 

The  contagious  and  infectious  diseases  are  of  particular  interest 
to  sanitarians,  because  it  is  believed  that  by  judicious  carrying  out 
of  sanitary  measures  they  can  be  prevented.  Hence  they  are  some- 
times termed  preventable  diseases.  Another  peculiarity  of  the  infec- 
tious diseases  is  that  they  usually  occur  in  groups  of  cases.  Thus, 
small-pox,  measles,  scarlet  fever,  typhus  fever,  diphtheria,  and  others 
of  the  class  do  not  occur  sporadically,  as  it  is  termed ;  that  is  to  say, 
it  rarely  happens  that  only  one  case  of  small-pox  is  observed  in  a 
locality,  unless  active  measures  are  at  once  taken  to  stamp  it  out. 
Usually  a  number  of  cases  occur  successively,  and  in  most  instances 
the  succeeding  cases  can  be  traced  ultimately  to  the  first  case. 

Contagious  and  infectious  diseases  frequently  appear  as  epidemics. 
Authorities  differ  as  to  the  proper  definition  of  an  epidemic;  that  is, 
given  the  population  of  a  place,  how  many  cases  of  an  infectious  or 
contagious  disease  are  necessary  before  the  disease  can  be  considered 
epidemic  at  such   place.     Tlie  following  formula  was  given  by  the 

25  (385) 


386  TEXT-BOOK  OF  HYGIENE. 

New  Orleans  Medical  and  Surgical  Association  in  response  to  the 
query:  "Under  what  circumstances  is  it  proper  to  declare  such  dis- 
eases (diphtheria,  scarlet  fever,  measles,  small-pox,  yellow  fever,  etc.) 
epidemic  in  a  place?"  The  answer  given  is  that  the  disease  should 
be  declared  epidemic  when  the  number  of  cases  should  reach  these 
proportions^ : — 

For   a   population   of 


100 

500 

5   per  cent. 
4    "   " 

2,000  to   5,000  . 

221/2  "  thousand. 

6,000  to  10,000  . 

16 

20,000  to  50,000  . 

8    "  ten  thousand 

50,000  to  100,000  . 

4    "   " 

200,000 

1    "   " 

A  disease  is  said  to  be  pandemic  when  it  spreads  rapidly  over  a 
great  extent  of  country,  and  endemic  when  it  is  constantly  present  in 
a  place.  Diseases  which  may  be  prevalent  in  certain  localities,  i.e., 
endemic,  not  infrequently  spread  over  larger  areas  of  country — over- 
flow their  borders,  as  it  were — and  become  epidemic  or  pandemic. 
Thus  cholera,  which  is  endemic  in  certain  districts  of  India,  fre- 
quently spreads  over  adjacent  territory,  and  at  times  the  epidemic 
wave,  as  it  has  been  called,  rolls  over  nearly  the  whole  world.  Plague, 
malarial  and  yellow  fevers  make  similar  epidemic  excursions  into 
other  countries,  or  sections  of  country,  at  a  distance  from  the  places 
where  they  are  endemic. 

Contagious  and  infectious  diseases  possess  another  peculiarity  in 
that  a  certain  time  is  required  after  the  introduction  of  the  poison 
into  the  system  before  the  disease  manifests  itself  by  its  typical  symp- 
toms. This  is  called  the  "stage  of  incubation,"  and  varies  for  dif- 
ferent diseases.  The  following  table  shows  the  stage  of  incubation  of 
a  number  of  such  diseases : — 

Table  LVI. 

Incubation  of  Infectious  Diseases. 

Measles   10  days. 

Small-pox   12  " 

Mumps    18  " 

Diphtheria    3  " 

Scarlet  fever    3  " 

Whooping-cough    •  .  •  •  14  " 

Typhoid  fever 14  " 

Typhus  fever   1  to  2  " 

Chicken-pox    4  " 

Erysipelas     4  " 


1  Public  Health,  vol.  vi,  p.  416,  417. 


THE  CARRIERS  OF  INFECTION.  387 

The  period  during  which  the  infectiveness  of  the  patient  lasts 
also  varies.  In  some  cases  it  probably  depends  upon  the  measures 
taken  to  prevent  the  spread  of  the  disease,  e.g.,  disinfection  of  the 
patient  and  his  surroundings. 

The  London  Clinical  Society  has  made  public  a  report  by  one  of 
its  committees,  which  has  for  several  years  carefully  studied  the  ques- 
tions of  incubation  and  the  duration  of  infection.  The  conclusions 
reached  do  not  differ  essentially  from  those  in  the  above  table,  but 
as  they  are  given  somewhat  more  in  detail  they  are  here  appended : — 

Diphtheria,  two  to  seven  days;    oftenest  two. 

Typhoid  fever,  eight  to  fourteen  days;    sometimes  twenty-three. 

Influenza,  one  to  four  days;    oftenest  three  to  four. 

Measles,  seven  to  eighteen  days;    oftenest  fourteen. 

Mumps,  two  to  three  weeks;    oftenest  three  weeks. 

Eubeola,  two  to  three  weeks. 

Scarlet  fever,  one  to  seven  days;   oftenest  two  to  four. 

Small-pox,  nine  to  fifteen  days;    oftenest  twelve. 

Further  investigations  were  made  with  regard  to  the  time  and 
duration  of  the  infective  period. 

Diphtheria  was  found  to  be  infective  during  the  period  of  incu- 
bation, attack,  and  convalescence. 

Mumps  and  rubeola  are  also  infective  for  three  or  four  days 
before  the  onset  of  the  parotiditis  and  appearance  of  the  rash. 

The  contagiousness  of  measles  speedily  disappears,  and  does  not 
continue  in  disinfected  persons  for  over  three  weeks. 

Typhoid  fever  is  infectious  from  the  time  of  onset  until  two 
weeks  after  the  fever  has  gone  and  convalescence  set  in. 

As  is  well  known,  the  contagiousness  of  scarlet  fever  varies 
greatly,  but  is  generally  continued  a  very  long  time — certainly  until 
desquamation  ceases,  and  sometimes  as  long  as  eight  weeks. 

THE  CARRIERS   OF  INFECTION. 

The  germs  of  infectious  or  contagious  diseases  may  be  conveyed 
either  by  inanimate  objects  which  come  in  contact  with  the  original 
source  of  the  disease  or  by  living  animals.  Of  the  former,  air,  food, 
water,  and  clothing,  the  latter  included  under  the  general  term 
"fomites,"  have  already  been  discussed.  The  transmission  of  disease 
by  animals,  especially  by  insects,  is  a  subject  which  has  assumed  con- 
siderable importance  of  late.  Leaving  aside  the  strictly  animal  dis- 
eases which  are  communicable  to  man,  as  anthrax,  glanders,  hydro- 
phobia, actinomycosis,  etc.,  we  will  consider  only  the  instances  in 


388  TEXT-BOOK  OF  HYGIENE. 

which  the  animal  acts  as  a  passive  agent,  or  an  intermediary  host. 
Thus,  oysters  from  sewage-polluted  beds  have  been  responsible  for 
epidemics  of  typhoid  fever.  The  bacillus  coli  has  been  found  in  the 
bodies  of  such  oysters,  while  Chantemesse  and  others  have  demon- 
strated the  possibility  of  oysters  carrying  the  typhoid  bacillus.  Certain 
snails  appear  to  be  intermediate  hosts  for  worms  parasitic  to  man.  The 
most  important  disease-carriers,  however,  are  the  insects.  These  may 
either  convey  the  germs  mechanically,  or  inoculate  them  by  stinging  or 
biting,  or  act  as  intermediate  hosts.  Thus,  flies  may  carry  on  their 
legs  or  within  their  bodies  the  germs  of  cholera,  typhoid  fever,  tuber- 
culosis, and  other  infectious  diseases,  and  deposit  them  on  the  food 
or  drink  which  is  subsequently  consumed  by  man.  There  is  abundant 
evidence  to  prove  that  in  many  instances  epidemics  of  typhoid  fever 
have  been  caused  through  the  agency  of  the  domestic  fly.  During 
the  Spanish-American  War  several  camps  were  visited  by  epidemics 
of  typhoid  fever,  and  in  every  instance  flies  were  demonstrated  as 
the  carriers  of  the  infection.  Fleas,  bed-bugs,  spiders,  and  lice 
may  and  often  do  transmit  disease  by  biting  the  individual  and 
inoculating  the  wound  with  the  bacteria  which  are  present  on  the 
proboscis.  In  the  case  of  mosquitoes,  there  are  certain  species 
which  act  as  the  intermediary  host  and  are  essential  factors  in 
the  propagation  of  disease.  Thus,  the  plasmodium  malarias,  a  pro- 
tozoon  which  is  the  specific  cause  of  that  disease,  undergoes  two 
cycles  of  development:  an  asexual  cycle  in  the  human  body,  and  a 
sexual  cycle  in  the  body  of  the  mosquito  of  the  genus  anopheles. 
When  the  mosquito  draws  the  blood  from  a  person  suffering  from 
malaria,  the  flagellate  forms  of  the  parasite  (microgametocytes)  are 
developed  in  its  stomach.  The  flagella  (microgametes,  or  male  ele- 
ments) are  discharged,  move  towards  other  non-flagellated  forms  of 
the  parasite  (macrogametes,  or  female  elements)  and  fertilize  them, 
The  fertilized  parasites  then  invade  the  intestinal  wall  and  form  a 
cystic  structure  (oocysts),  containing  numerous  minute  rods  or  sporo- 
zooits  which  have  resulted  from  the  segmentation  of  the  parasite. 
The  oocysts  eventually  rupture  and  the  sporozooits  find  their  way 
into  the  veneno-salivary  glands  of  the  mosquito,  to  be  introduced  into 
the  next  person  who  is  so  unfortunate  as  to  receive  the  sting  of  the 
infected  mosquito.  Once  in  the  circulation  of  man,  the  parasites  in- 
vade the  red  blood-cells  and  there  undergo  multiplication  by  segmen- 
tation. 

Eecently  it  has  been  demonstrated  that  yellow  fever  is  transmitted 
by  another  species  of  mosquito,  stegomyia  fasciata,  probably  in  a  simi- 


THE  CARRIERS  OF  INFECTION.  389 

lar  manner;  while  Manson  has  shown  that  the  mosquito  (culex) 
acts  as  the  intermediary  host  of  the  parasite  of  elephantiasis  (filaria 
sanguinis  hominis) . 

Of  the  higher  animals,  rats  have  been  shown  to  be  the  carriers  of 
bubonic  plague,  a  disease  to  which  they  are  subject. 

The  prophylaxis  of  diseases  transmitted  by  insects  and  the  higher 
animals  is  to  be  accomplished  by  cleanliness,  destruction  of  the  pests 
whenever  possible,  and  avoidance  of  contact  with  animals  harboring 
the  germs  of  disease. 


QUESTIONS  TO  CHAPTER  XVI. 

CONTAGION  AND   INFECTION.     ' 

What  is  the  difference  between  a  contagious  and  an  infectious  disease? 
Give  examples  of  each.  What  diseases  do  not  belong  to  either  of  these  classes? 
What  other  names  might  be  given  to  contagious  and  infectious  diseases?  How 
do  they  usually  occur?  What  are  their  exciting  causes?  How  may  they  be 
prevented  ? 

What  is  an  epidemic?  When  may  a  disease  be  declared  epidemic  in  a 
city  of  10,000  persons?  Wlien  is  a  disease  pandemic?  When  endemic?  May 
an  endemic  disease  become  epidemic  or  pandemic? 

What  other  peculiarities  do  contagious  and  infectious  diseases  possess? 
What  diseases  have  the  longest  period  of  incubation?  What  ones  the  shortest? 
How  does  the  period  of  incubation  support  the  germ  theory?  What  other 
definite  period  has  each  of  these  diseases?  What  is  the  usual  duration  of  a 
case  of  typhoid  fever?  Of  scarlet  fever?  Of  measles?  Does  this  support  the 
germ  theorj^?  How  long  does  a  typhoid  patient  remain  infective?  How  long 
a  diphtheria  patient?  A  scarlet-fever  patient?  (See  chapters  on  School  Hy- 
giene and  Quarantine.)  Upon  what  does  the  danger  and  period  of  infective- 
ness  depend?  Are  these  diseases  all  likely  to  confer  immunity  against  future 
attacks?  Which  are  most  likely  to  do  this?  What  role  do  animals  play  in 
the  transmission  of  disease?  Name  insects  which  act  as  intermediate  hosts 
in  the  transmission  of  malaria.  Of  yellow  fever.  Describe  the  mode  of 
transmission  of  malaria  by  the  mosquito. 


(390) 


CHAPTER  XVII. 

HISTORY  OF  EPIDEMIC  DISEASES. 

An  important  part  of  the  knowledge  of  the  sanitarian  is  that 
which  relates  to  the  history  of  the  great  epidemic  diseases  which  have 
at  various  periods  devastated  large  areas  of  the  inhabited  world.  In 
this  chapter  the  history  of  these  diseases  will  be  briefly  traced.  Al- 
though some  of  these  diseases  have  nearly  or  quite  ceased,  a  knowledge 
of  their  habits  and  of  the  causes  that  finally  led  to  their  extinction 
is  of  great  value,  for  the  reason  that  the  principles  and  measures  of 
prevention  which  were  effective  in  times  past  are  the  same  which 
must  apply  at  present  and  in  the  future.  Hence,  time  spent  in  look- 
ing back  over  the  fields  traversed  and  noting  victories  won  will  not  be 
wasted. 

The  epidemic  diseases  which  will  here  claim  attention  are  the 
Oriental  plague,  the  sweating  sickness,  small-pox,  Asiatic  cholera; 
typhus,  typhoid,  scarlet,  relapsing,  and  yellow  fevers;  diphtheria, 
dengue,  epidemic  influenza,  and  syphilis.  In  addition,  some  informa- 
tion will  be  given  on  certain  of  the  diseases  of  animals  transmissible 
to  man.  Among  these  are  sheep-pock,  actinomycosis,  bovine  tuber- 
culosis (perlsucht),  rabies,  anthrax  (milzbrand),  and  glanders. 

THE  ORIENTAL  PLAGUE. 

The  Oriental  plague,  bubonic  plague,  the  black  death,  or  simply 
the  '^plague,"  or  great  pestilence,  overtopping  in  its  fatality  all  other 
pestilences,  is  mentioned  by  a  number  of  the  Greek  and  Latin  medical 
authors.  The  first  account  which  clearly  refers  only  to  this  disease 
is  given  by  Procopius.  According  to  this  and  other  contemporary 
authors,  the  disease  began  to  spread  in  the  year  542  from  Lower 
Egypt,  passing  in  one  direction  along  the  coast  of  Northern  Africa. 
and  in  the  other  invading  Europe  by  way  of  Syria  and  Palestine.  In 
the  course  of  the  succeeding  years  this  pandemic  reached  "the  limits 
of  the  inhabited  earth,"  in  the  language  of  the  writers  of  the  day. 
The  disease  prevailed  about  half  a  century,  and  produced  the  greatest 
devastation  wherever  it  appeared.  "Cities  were  devastated,  the  country 
converted  into  a  desert,  and  the  wild  beasts  found  an  asylum  in  the 
abandoned  haunts  of  man."^ 


^  Warnefricfl,  quoted  by  Hirsch,  Hist-Geographische  Pathologie,  I,  p.  350. 

(391) 


392  TEXT-BOOK  OF  HYGIENE. 

The  plague  is  an  acute  infectious  disease  caused  by  a  bacillus 
{iacillus  pestis)  and  characterized  by  an  affection  of  the  Ij^mphatic 
system,  i.e.,  inflammation  and  swelling  of  the  external  and  internal 
IjTuphatic  glands.  Accessory  symptoms  are  petechial  spots  upon  the 
skin,  and  hemorrhages  from  various  organs,  as  the  stomach,  nose, 
kidneys,  rectum,  and  uterus.  Those  attacked  suffer  in  varied  degrees 
of  intensity.  In  some,  a  fulminant  form  occurs  which  carries  off  the 
patient  within  three  days ;  there  is  another  class  of  cases  in  which 
buboes  develop,  with  accompanying  fever  and  hemorrhages;  and 
finall}',  a  light  form,  rarely  fatal,  in  which  only  the  local  symptoms 
are  manifested.  In  the  great  pandemic  plague  of  the  fourteenth  cen- 
tury cough  and  bloody  expectorations  were  very  frequent.  In  the 
later  epidemics  hemorrhage  from  the  lungs  has  been  rarely  noticed 
as  a  s}Tnptom. 

About  the  middle  of  the  fourteenth  century  the  bubonic  plague 
made  a  second  incursion  into  Europe  from  its  home  in  the  East.  A 
most  graphic  description  of  its  ravages  is  given  by  Boccaccio  in  the 
"Decameron."  This  author  states  that  in  1359,  'iDctween  March  and 
July  following,  according  to  authentic  reckonings,  upward  of  100,000 
souls  perished  in  the  city  (Florence)  ;  whereas,  before  that  calamity 
it  was  not  supposed  to  contain  so  many  inhabitants." 

This  terrible  epidemic  was  forcibly  characterized  by  its  com- 
mon name,  "the  black  death."  Hecker  estimates  that  during  its  con- 
tinuance, from  1347  to  1351,  25,000,000 — one-fourth  of  the  probable 
total  population  of  Europe — died.  In  various  cities  the  mortality  was 
—in  London,  100,000;  in  Paris,  50,000;  in  Venice,  100,000;  in 
Avignon,  60,000;  in  Marseilles,  16,000,  in  one  month.  It  was  said 
that  in  all  England  scarcely  a  tenth  part  of  the  population  escaped 
death  from  the  disease. 

The  moral  effects  of  this  great  pandemic  of  the  plague  were 
hardly  less  deplorable  than  the  physical.  Eeligious  fanaticism  held 
full  sway  throughout  Europe,  finding  its  vent  in  all  manner  of  ex- 
cesses. The  so-called  Brotherhood  of  the  Cross,  otherwise  known  as 
the  Order  of  Flagellants,  which  had  arisen  in  the  thirteenth  ceutury, 
but  had  been  suppressed  by  the  ecclesiastical  authorities,  was  revived 
during  the  black  pestilence,  and  large  numbers  of  these  religious 
enthusiasts  roamed  through  the  various  countries  on  their  great  pil- 
grimages. Their  power  increased  to  such  a  degree  that  Church  and 
State  were  forced  to  combine  for  their  suppression.  One  consequence 
of  this  fanatical  frenzy  was  the  persecution  of  the  Jews.  These  were 
accused  of  being  the  cause  of  every  evil  that  befell  mankind,  and 
many  were  put  to  death. 


THE  ORIENTAL  PLAGUE.  393 

In  the  fifteenth  and  sixteenth  centuries  the  plague  was  generally 
diffused  throughout  Europe,  and  in  the  second  third  of  the  seventeenth 
century  its  final  incursion  into  the  Occident  took  place.  The  great 
epidemic  in  London,  so  graphically  described  by  Defoe,^  occurred  in 
1665.  In  the  early  part  of  the  eighteenth  century  (1720)  the  plague 
visited  Marseilles  and  Toulon ;  from  1769  to  1773  it  was  epidemic  in 
Moldavia,  \Yallachia,  Poland,  and  Southern  Kussia;  near  the  close 
of  the  eighteenth  and  in  the  beginning  of  the  nineteenth  century, 
in  Transylvania,  Wallachia,  Southern  Eussia,  and  Greece.  In  1878 
and  1879,  and  in  1885,  the  plague  threatened  a  new  irruption  into 
European  territory,  being  epidemic  in  the  district  of  Astrachan,  on  the 
Caspian  Sea.  In  1894  it  was  reported  epidemic  in  certain  parts  of 
China. 

Although  the  bubonic  plague  has  never  been  observed  in  America 
in  epidemic  form,  and  has  spared  Enrope  almost  entirely  during  the 
present  century,  it  still  persists  in  certain  countries  of  Asia  and 
Africa,  especially  in  Arabia,  Mesopotamia,  Persia,  and  the  coast  of 
Tripoli.  A  number  of  cases  of  plague  occurred  a  few  years  ago  in 
San  Francisco,  in  the  Chinese  quarters. 

The  older  authors  ascribed  the  origin  of  the  plague  to  various  real 
or  supposed  conditions.  Comets,  conjunctions  of  the  planets,  "God's 
just  punishment  for  our  sins,"  and  similar  causes  were  advanced 
to  account  for  the  outbreaks.  Most  of  the  writers  of  the  post-medieval 
and  modern  epochs  ascribed  the  disease  to  meteorological  conditions. 
Observing  the  fact  that  the  plague  never  advanced  into  the  torrid 
zone,  and  that  an  epidemic  generally  ended  with  the  advent  of  hot 
weather,  a  high  temperature  v;as  believed  to  be  incompatible  with  the 
existence  of  an  epidemic,  and  a  cold  or  temperate  climate  was  con- 
sidered necessary  to  an  outbreak  of  the  disease.  The  exceptions  to 
the  rule  are  so  numerous,  however,  that  the  theory  of  the  climatic 
or  meteorological  origin  of  the  plague  failed  of  support.  The  theory 
which  ascribed  the  origin  of  the  epidemics  to  the  influence  of  cer- 
tain hot  and  dry  winds  or  a  high  humidity  is  also  insufficient.  Cer- 
tain geological  formations  have  been  supposed  to  furnish  favorable 
conditions  for  the  development  of  the  disease.  Facts  show,  however, 
that  the  disease  has  prevailed  epidemically  and  endemically  in  vari- 
ous parts  of  the  earth,  and  of  the  most  diverse  geological  character. 
A  certain  elevation  above  sea-level  has  been  held  to  confer  immunity, 
but  recent  observations  in  India  show  that  this  belief  is  unfounded. 


Journal  of  the  Plague  in  London. 


394  TEXT-BOOK  OF  HYGIENE. 

even  places  at  an  elevation  of  10,000  feet  above  sea-level  giving  no 
security  against  attack. 

There  is,  however,  one  point  upon  which  nearly  all  writers  who 
mention  the  fact  at  all  agree.  That  is  that  bad  hygienic  conditions 
are  always  present  where  plague  prevails.  Nearly  all  observers  who 
have  left  their  impressions  on  record  mention  the  accumulation  of 
filth  in  the  houses  and  streets,  deficient  removal  of  excrementitious 
and  other  sewage  matters,  crowding  and  imperfect  ventilation  of 
dwellings  as  causes  favoring  the  development  and  spread  of  the  pes- 
tilence. All  point  out  the  necessity  of  the  removal  of  these  evils  as 
the  most  important  prophylactic  measure  to  be  adopted,  and  all  of 
them  call  attention  to  the  fact  that  those  classes  of  the  population 
most  exposed  to  these  unfavorable  influences  suffer  most  from  the 
violence  of  the  epidemic. 

The  later  reports  of  the  epidemics  in  Persia,  India,  Mesopotamia, 
and  Eussia  agree  in  asserting  that  nothing  seems  to  have  promoted 
the  epidemic  and  endemic  prevalence  of  the  plague  so  much  as  the 
material  wretchedness  of  the  inhabitants  of  those  countries.  In  a 
collection  of  papers  on  the  plague,  printed  by  a  British  Parliamentary 
Commission  in  1879,  occur  these  statements:  "The  filth  is  every- 
where," says  Mr.  Eennie,  one  of  the  reporters — "in  their  villages,  their 
houses,  and  their  persons.  Their  dwellings  are  generally  low  and  ill- 
ventilated,  except  through  their  bad  construction;  and  the  advan- 
tage of  the  natives  in  other  parts  of  India,  of  living  in  the  open  air, 
is  lost  to  the  villagers  of  Ghurwal,  from  the  necessity  of  their  crowd- 
ing together  for  mutual  warmth  and  shelter  against  the  inclemency 
of  the  weather."  Dr.  Dickson,  reporting  on  the  plague  in  Irak  Arabi, 
in  1876,  saj^s:  "The  most  palpable  and  evident  of  all  the  causes 
which  predispose  an  individual  to  an  attack  of  plague  during  an 
epidemic  outbreak  is  poverty.  No  other  m^alady  shows  the  influence 
of  this  factor  in  so  striking  a  degree;  so  much  so,  indeed,  that  Dr. 
Cabiadis  styles  the  plague  miserice  morhis.  In  his  experience  (1876- 
77,  in  Bagdad)  he  found  that  the  poor  were  seldom  spared,  the 
wealthy  hardly  ever  attacked."^ 

The  manner  of  the  transmission  of  the  plague  has  now  been  dis- 
covered to  be  by  infected  rats  and  fleas.  Hence,  it  may  be  termed  an 
infectious  disease,  although  it  is  not  improbable  that  it  may  be  com- 
municated by  direct  contact  both  of  persons  and  of  fomites. 

These  considerations  indicate  the  measures  of  prevention  to  be 


*Hirsch,  op.  cit.,  p.  370. 


THE  SWEATING  SICKNESS.  395 

adopted.  They  consist  of  a  rigid  quarantine  of  persons  and  fomites, 
prompt  and  complete  isolation  of  infected  individuals  and  localities, 
and  destruction  (by  fire)  or  thorough  disinfection  by  steam  or  sul- 
phurous-acid gas  of  all  materials  capable  of  conveying  the  virus  of 
the  disease,  and  especially  the  destruction  of  rats. 

THE  SWEATING  SICKNESS. 

This  name  concisely  characterizes  an  epidemic  disease  which 
for  the  first  time  appeared  in  the  city  of  London  and  other  parts  of 
England  in  the  autumn  of  1485.  According  to  Lord  Bacon/  the 
disease  began  about  the  21st  of  September  and  lasted  until  near  the 
end  of  October.  It  broke  out  a  second  time  in  the  summer  of  1507; 
a  third  time  in  July,  1518,  spreading  in  the  course  of  six  months 
throughout  England.  In  May,  1529,  the  disease  made  its  appearance 
again  in  the  latter  country,  spreading  thence  over  a  great  part  of 
the  continent  of  Europe.  Another  very  malignant  epidemic  broke 
out  in  the  spring  of  1541,  lasting  through  the  summer,  and  limited 
in  its  ravages  to  England. 

With  this  outbreak,  in  1551,  this  disease  disappeared  entirely  in 
England,  and  has  not  re-appeared  there  up  to  the  present  day.  In  the 
beginning  of  the  eighteenth  century,  however,  a  disease  very  similar  in 
its  symptoms  and  course  broke  out  in  Picardy  and  other  districts  of 
Northern  France,  being  confined  for  a  number  of  years  to  this  sec- 
tion of  the  country.  Toward  the  end  of  the  century  it  spread  to  the 
south  of  France,  and  since  that  time  has  appeared  epidemically  at 
intervals,  195  distinct  outbreaks  having  been  observed  in  the  course 
of  168  years,  from  1718  to  1887.  The  disease  has  frequently  appeared 
in  Italy  since  1755,  and  in  various  parts  of  Germany  since  1801.  In 
Belgium  it  has  been  observed  at  a  few  places  within  the  present 
century. 

The  disease  appeared  suddenly,  often  at  night-time.  The  patient 
was  attacked  with  palpitation  of  the  heart,  dyspnea,  great  anxiety  and 
oppression,  and  profuse  perspiration.  A  miliary  eruption  often  ap- 
peared on  the  skin.  In  favorable  cases  these  symptoms  diminished 
in  the  course  of  one  or  two  days,  the  urinary  secretion,  which  had 
been  suppressed,  was  restored,  and  the  perspiration  became  gradually 
less  free.  Recovery  ensued  in  from  one  to  two  weeks.  In  grave  cases 
there  were,  in  the  beginning  of  the  attack,  violent  headache,  delirium, 


*  History  of  Henry  VII. 


396  TEXT-BOOK  OF  HYGIENE. 

convulsions,  followed  by  a  comatose  condition,  from  which  the  patients 
rarely  recovered. 

This  disease  is  undoubtedly  of  an  infectious  nature,  as  proved  by 
its  raipid  spread  and  limitation  to  certain  localities.  It  appears  most 
frequently  in  the  spring  and  summer,  and  is  nearly  always  observed  in 
marshy  or  damp  localities.  Its  spread  is  favored  by  a  high  tempera- 
ture and  humidity.  There  is  no  apparent  connection  between  the 
outbreaks  of  the  sweating  sickness  and  overcrowding  or  other  unsani- 
tary conditions;  in  fact,  it  is  stated  by  numerous  observers,  both  old 
and  recent,  that  children,  the  aged,  and  generally  the  poorer  classes 
were  remarkably  exempt  from  the  disease.  The  recent  epidemic  in 
France,  in  1887,  was  investigated  by  Dr.  Brouardel,  Chanteraesse, 
and  other  epidemiologists,  but  no  trustAvorthy  conclusions  as  to  the 
nature  of  the  disease  have  yet  been  reached. 

Since  the  first  appearance  of  Asiatic  cholera  in  France,  in  1833, 
an  apparently  intimate  connection  has  been  observed  between  the  oc- 
currences of  that  disease  and  outbreaks  of  sweating  sickness.  A 
disease  strongly  resembling  the  sweating  sickness  has  also  been  ob- 
served in  India  in  districts  contiguous  to  places  where  cholera  was 
at  the  time  epidemic.^ 

SMALL=POX. 

The  earliest  details  concerning  small-pox  are  derived  from  cer- 
tain Chinese  records,  according  to  which  it  appears  that  this  disease 
was  known  in  China  upward  of  2000  years  ago.  It  was  also  known  at 
a  very  early  period  in  India.  It  is  believed  to  have  been  introduced 
into  Europe  in  the  second  century  by  a  Eoman  army  returning  from 
Asia.  It  is  believed  that  the  Emperor  Aurelius  died  of  small-pox, 
which  prevailed  in  his  army  at  the  time  of  his  death. 

The  first  distinct  references  to  small-pox  in  medical  literature 
occur  in  the  writings  of  Galen,  in  the  second  century.  Ehazes,  in  the 
ninth  century,  wrote  upon  the  disease,  describing  it  very  accurately. 

The  almost  universal  susceptibility  to  small-pox  caused  wide- 
spread devastation  wherever  it  appeared  previous  to  the  introduction 
of  vaccination.  The  statement  is  made  that  in  England,  in  the  last 
century,  about  one  person  in  every  three  was  badly  pock-marked.  The 
mortality  from  the  disease  was  exceedingly  great,  being,  in  the  latter 
half  of  the  eighteenth  century,  about  3000  per  million  of  inhabitants 
annually. 


5  Murray,    Madras  Quart.  Med.   Journ.,   1840-41.     Quoted  in  Hirsch,   loc. 
cit.,  p.  83. 


SMALL-POX.  S97 

In  India  tlife  mortality  from  small-pox  has  been  exceedingly  great 
within  the  last  twenty  years.  From  1866  to  1869,  140,000  persons 
died  in  the  Presidencies  of  Bombay  and  Calcutta,  having  a  population 
of  about  40,000,000.  Several  years  later,  from  1873  to  1876,  700,000 
died  from  this  disease. 

China,  Japan,  Cochin  China,  the  islands  of  the  China  Sea,  and 
Corea  are  frequently  ravaged  by  small-pox.  In  the  latter  country 
nearly  all  the  inhabitants  are  said  to  bear  evidence  of  an  attack  of 
the  disease. 

The  Samoyedes,  Ostiaks,  and  other  natives  of  Eastern  Siberia 
have  frequently  suffered  from  devastating  epidemics.  In  Kamtchatka 
the  disease  was  introduced  in  1767  and  produced  frightful  ravages. 
Many  villages  were  completely  depopulated. 

In  Mexico  small-pox  was  introduced  by  the  Spaniards  in  1520. 
In  a  short  time  it  carried  ofE  over  3,500,000  of  the  natives.  In  the 
Marquesas  Islands  one-fourth  of  the  inhabitants  have  fallen  victims 
to  the  disease  since   1863.  . 

It  was  first  introduced  into  the  Sandwich  Islands  in  1853,  and 
carried  off  8  per  cent,  of  the  natives. 

Australia,  Tasmania,  New  Zealand,  and  the  Fejee  Archipelago 
remain  exempt  to  the  present  day  from  small-pox.  It  has  several 
times  been  carried  to  Australia  by  vessels,  but  has  always  been 
promptly  checked  by  the  vigilance  of  the  authorities. 

On  the  Western  Hemisphere  small-pox  was  unknown  before  the 
arrival  of  the  European  conquerors.  It  has  been  spread  by  the  whites 
or  imported  African  slaves  to  nearly  all  the  Indian  tribes  of  both 
continents.  When  it  attacks  large  communities  unprotected  by  pre- 
vious outbreaks  of  the  disease,  or  by  inoculation  or  vaccination,  its 
ravages  are  frightful.  The  mortality  of "  unmodified  small-pox ,  is 
usually  between  30  and  40  per  cent. 

Small-pox  is  a  highly  contagious  and  infectious  disease.  It  is 
produced  by  actual  contact,  by  inoculation,  and  by  inhaling  an  at- 
mosphere charged  with  the  poison.  In  order  to  cause  an  outbreak 
two  factors  are  necessary.:  first,  a  number,  of  individuals  susceptible 
to  the  disease,  and,  second,  the  introduction  into  the  body  in  some 
manner,  of  the  virus  upon  which  it  depends. 

Small-pox  is  spread  from  (1)  persons  sick  with  the  disease;  (3)' 
others,  not  themselves  sick  or  susceptible,  but  coming  in  contact  with 
the  poison;  (3)  fomites  (cotton,  wool,  etc.),  and  (4)  the  bodies  of 
persons  dead  with  small-pox.     It  is  also  probable  that  the  air  in  the 


39g  TEXT-BOOK  OF  HYGIENE. 

immediate  vicinity  of  a  person  sick  with  small-pox  becomes  charged 
with  the  poison  and  able  to  convey  the  disease.  It  is  at  present  impos- 
sible to  fix  the  distance  to  which  this  infectiousness  of  the  air  ex- 
tends, but  it  does  not  ordinarily  reach  beyond  the  room  in  which  the 
patient  is  confined. 

It  is  a  fact  of  common  observation  that  the  darker  races  are 
more  commonly  attacked,  and  the  disease  is  likewise  more  fatal 
among  them.  The  mortality  among  negroes  is  much  larger  than 
among  other  races. 

It  is  a  current  belief  that  small-pox  is  only  contagious  after  the 
development  of  the  pustules.  This  is  a  serious  error.  It  is  probably 
contagious  in  all  stages  of  the  disease;  certainly  as  early  as  the  first 
appearance  of  the  eruption,  and  probably  even  in  the  stage  of  prelim- 
inary fever. 

One  attack  of  small-pox  usually  confers  immunity  from  the  dis- 
ease for  life.  This  rule  has  its  exceptions,  however,  which,  if  not 
numerous,  are  yet  not  infrequent.  The  author  has  seen  a  case  in 
which  the  patient  suffered  from  a  third  attack  of  the  disease. 

The  popular  belief,  that  persons  suffering  from  any  acute  or 
chronic  disease  are  less  liable  to  be  attacked  by  small-pox  than  those 
at  the  time  in  good  health,  is  erroneous.  On  the  contrary,  the  subjects 
of  chronic  disease,  such  as  consumption  or  dyspepsia,  are  much  more 
liable  to  succumb  to  an  attack  of  small-pox  than  persons  previously  in 
good  health. 

It  is  true,  however,  that  individuals  suffering  from  some  other 
acute  infectious  disease,  like  scarlet  fever,  measles,  typhoid  fever, 
etc.,  are  generally,  though  not  absolutely,  exempt  from  an  attack  of 
small-pox  during  the  time  they  are  sick  with  such  disease.  But  if 
they  are  exposed,  after  recovery,  to  the  small-pox  infection,  their 
liability  to  an  attack  is  as  great  as  in  those  who  have  not  passed 
through  a  similar  disease.  A  number  of  cases  have  been  reported  by 
Curschmann,^  in  which  infection  by  small-pox  took  place  on  the  day 
in  which  convalescence  from  typhoid  fever  was  established. 

The  author  has  reported  a  case''  in  which  the  patient  passed 
through  an  attack  of  erysipelas  during  the  incubative  stage  of  small- 
pox. From  all  the  evidence  attainable,  the  incubative  stage  was  not 
prolonged  by  the  intercurrent  erysipelas. 

Epidemics  of  small-pox  usually  begin  in  the  autumn  or  winter, 
and  lessen  in  violence  as  warmer  weather  approaches.     The  spread 


'Ziemssen's   Cyelopoedia,   vol.   ii. 
Medical  News,  July  7,  1883. 


SMALL-POX.  399 

of  the  disease  is  slow  at  first,  increasing  in  rapidity  as  the  foci  of 
infection  multiply. 

When  the  poison  is  imported  into  a  community  late  in  the  spring 
or  during  the  summer,  the  increase  in  the  number  of  cases  is  ex- 
ceedingly gradual  until  colder  weather  sets  in.  If  it  is  introduced  dur- 
ing the  winter,  the  disease  spreads  much  more  rapidly,  but  decreases. 
and  sometimes  almost  disappears,  during  the  summer.  On  the  return 
of  cold  weather,  however,  the  epidemic  starts  out  with  a  new  lease 
of  activity  and  presents  great  difficulties  to  its  restriction. 

A  number  of  observers,  among  whom  are  Coze  and  Feltz,  Lugen- 
biihl,  Weigert,  Strauss,  Garre,  and  Wolff,  claim  to  have  discovered 
specific  organisms  in  the  contents  of  variolous  pustules,  in  the  blood 
of  patients  with  the  disease,  and  in  vaccine  lymph.  Expert  bacterio- 
logists are,  however,  not  willing  to  accept  the  evidence  hitherto  fur- 
nished as  conclusive. 

Inoculation. — The  prevention  or  restriction  of  such  a  universal 
and  fatal  pestilence  as  small-pox  is  a  matter  of  the  deepest  impor- 
tance. The  first  attempt  to  limit  its  fatality  dates  from  the  end  of 
the  seventeenth  century.  It  became  generally  known  in  Europe, 
about  the  year  1700,  that  tlie  intentional  inoculation  of  variolous 
matter  into  healthy  individuals  induced  an  attack  of  the  disease,  which 
generally  ran  through  its  various  stages  with  less  virulence  than  when 
the  disease  was  contracted  in  the  usual  manner.  In  1716  and  1717  two 
papers  were  published  in  the  "Transactions  of  the  Eoyal  Society  of 
England"  giving  an  account  of  the  process  of  inoculation.  The  at- 
tention of  the  public  was  especially  directed  to  the  matter,  however, 
by  the  famous  letter  of  Lady  Mary  Wortley  Montagu,  dated  April 
1,  1717.  This  letter  is  as  follows^:  "Apropos  of  distempers,  I  am 
going  to  tell  you  a  thing  that  will  make  you  wish  yourself  here.  The 
small-pox,  so  fatal  and  so  general  amongst  us,  is  here  entirely  harm- 
less by  the  invention  of  ingrafting,  which  is  the  term  they  give  it. 
There  is  a  set  of  old  women  who  make  it  their  business  to  perform 
the  operation  every  autumn,  in  the  month  of  September,  when  the 
great  heat  is  abated.  People  send  to  one  another  to  know  if  any  of 
their  family  has  a  mind  to  have  the  small-pox ;  they  make  parties  for 
this  purpose,  and  when  they  are  met — commonly  fifteen  or  sixteen 
together — the  old  woman  comes  with  a  nut-shell  full  of  the  matter  of 
the  best  sort  of  small-pox,  and  asks  what  veins  you  please  to  have 
opened.  She  immediately  rips  open  that  you  offer  to  her  with  a  large 
needle — which  gives  you  no  more  pain  than  a  common  scratch — and 

*The  letter  is  addressed  to  Mrs.  S.  C.   (Sarah  Chiswell). 


400  TEXT-BOOK  OF  HYGIENE. 

puts  into  the  vein  as  much  matter  as  can  lie  upon  the  head  of  her 
needle,  and  after  that  binds  up  the  little  wound  with  a  hollow  bit 
of  shell ;  and  in  this  manner  opens  four  or  five  veins.  The  Grecians 
have  commonly  the  superstition  of  opening  one  in  the  middle  of  the 
forehead,  one  in  each  arm,  and  one  on  the  breast,  to  make  the  sign 
of  the  cross;  but  this  has  a  very  ill  efEect,  all  these  wounds  leaving 
little  scars,  and  is  not  done  by  those  that  are  not  superstitious,  who 
choose  to  have  them  in  the  leg  or  that  part  of  the  arm  that  is  con- 
cealed. The  children  or  young  patients  play  together  all  the  rest  of 
the  day,  and  are  in  perfect  health  until  the  eighth.  Then  the  fever 
begins  to  seize  them,  and  they  keep  their  beds  two  days,  very  seldom 
three.  They  have  rarely  above  twenty  or  thirty  in  their  faces,  which 
never  mark;  and  in  eight  days'  time  they  are  as  well  as  before  their 
illness.  Where  they  are  wounded  there  remain  running  sores  during 
the  distemper,  which  I  don't  doubt  is  a  great  relief  to  it.  Every  year 
thousands  undergo  this  operation;  and  the  French  ambassador  says 
pleasantly:  'They  take  the  small-pox  here  by  way  of  diversion,  as 
they  take  the  waters  in  other  countries.'  There  is  no  example  of  any 
one  that  has  died  in  it,  and  you  may  believe  that  I  am  well  satisfied 
of  the  safety  of  the  experiment,  since  I  intend  to  try  it  on  my  dear 
little  son. 

"I  am  patriot  enough  to  take  pains  to  bring  this  useful  invention 
into  fashion  in  England ;  and  I  should  not  fail  to  write  to  some  of  our 
doctors  very  particularly  about  it,  if  I  knew  any  of  them  that  I 
thought  had  virtue  enough  to  destroy  such  a  considerable  branch  of 
their  revenue  for  the  good  of  mankind.  But  that  distemper  is  too 
beneficial  to  them  not  to  expose  to  all  their  resentment  the  hardy 
wight  that  should  undertake  to  put  an  end  to  it.  Perhaps,  if  I  re- 
turn, I  may,  however,  have  courage  to  war  with  them." 

Soon  after  the  date  of  this  letter  the  writer's  son  was  inoculated 
in  Turkey,  and  four  years  later  her  daughter  also,  being  the  first  sub- 
ject inoculated  in  England.  The  practice  soon  became  popular,  but 
several  fatal  cases  among  prominent  families  brought  it  into  disrepute, 
and  for  about  twenty  years  very  few  inoculations  were  made  in  Eng- 
land. It  was  revived  about  the  middle  of  the  century  by  the  founding 
of  a  small-pox  and  inoculation  hospital  in  London.  This  continued 
in  operation  until  1832.  The  records  of  this  institution  showed  that 
only  three  in  a  thousand  died  of  the  disease  thus  communicated.  The 
practice  has  now  fallen  into  desuetude,  being  superseded  by  vaccina- 
tion and  prohibited  by  law  in  England. 

Inoculation  was  introduced  into  this  country  in  1721  by  Dr.  Zab- 


SMALL-POX.  401 

diel  Boylston,  of  Boston,  who  had  his  attention  directed  to  the  prac- 
tice by  Cotton  Mather,  the  eminent  divine."  During  1721  and  1722, 
286  persons  were  inoculated  by  Boylston  and  others  in  Massachu- 
setts, and  6  died.  These  fatal  results  rendered  the  practice  unpopular, 
and  at  one  time  the  inoculation  hospital  in  Boston  was  closed  by 
order  of  the  Legislature.  Toward  the  end  of  the  century  an  inoculat- 
ing hospital  was  again  opened  in  that  city. 

Early  in  the  eighteenth  century  inoculation  was  extensively 
practiced  by  Dr.  Adam  Thomson,  of  Maryland,  who  was  instrumental 
in  spreading  a  knowledge  of  the  practice  throughout  the  Middle 
States.^" 

In  China  and  India,  and  perhaps  other  eastern  countries,  inocu- 
lation was  practiced  at  a  very  early  period. 

The  inoculation  of  variolous  matter,  although  it  mitigated  to 
a  very  great  degree  the  attack  of  small-pox  following,  had  one  very 
serious  objection,  aside  from  the  small  death-rate  which  was  a  direct 
consequence  of  it.  This  was  the  fact  that  inoculation  always  pro- 
duced small-pox,  and  thus  assisted  in  propagating  the  disease;  for. 
however  mild  the  induced  disease  might  be,  the  inoculated  individual 
was  liable  to  communicate  small-pox  to  others  in  the  most  virulent 
form.  Hence,  nothing  short  of  universal  inoculation,  which  was  mani- 
festly impracticable,  would  succeed  in  reducing  the  danger  from  the 
disease. 

Vaccination. — It  had  been  noticed  at  various  times  that  a  pus- 
tular disease  which  sometimes  appears  on  the  udders  of  cows,  called 
cow-pox,  had  not  infrequently  been  transmitted  to  the  hands  of  the 
dairy-maids  and  others  having  much  to  do  with  cows.  In  the  course 
of  time  it  was  also  noticed  that  persons  who  had  been  thus  attacked 
never  suffered  from  small-pox.  This  protective  power  of  cow-pox  was 
known  as  early  as  1713,  and  in  1774  Benjamin  Jesty,  a  Gloucestershire 
farmer,  performed  vaccination  for  the  first  time  on  record,  inoculating 
his  wife  and  two  sons  with  cow-pox  matter  as  a  protection  against 
small-pox. 

It  is  said  that  when  it  became  known  that  Jesty  had  vaccinated 
his  wife  and  sons,  "his  friends  and  neighbors,  who  had  hitherto  looked 
upon  him  with  respect,  on  account  of  his  superior  intelligence  and 
honorable  character,  began  to  regard  him  as  an  inhuman  brute,  who 

"Dr.  John  T?.  Quinan  (Md.  Med.  Journ.,  June  23  and  30,  1883)  believes 
the  claim  of  Dr.  Boylston  to  be  the  first  American  inoculator  open  to  ques- 
tion. The  evidence  presented  is,  however,  insufficient  to  discredit  the  claim 
of  the  Boston   physician. 

""See  Quinan,  loc.  cit.,  p.  114. 

26 


402  TEXT -BOOK  OF  HYGIENE. 

could  dare  to  practice  experiments  upon  his  family,  the  sequel  of 
which  would  be^  as  they  thought,  their  metamorphosis  into  horned 
beasts.  Consequently  the  worthy  farmer  was  hooted  at>  reviled,  and 
pelted  whenever  he  attended  the  markets  in  his  neighborhood."^^ 

In  1791  a  school  teacher  in  Holstein  also  inoculated  three  boys 
with  the  matter  of  cow-pox,  but  nothing  is  known  of  the  subsequent 
history  of  these  cases. 

Although  the  above  facts  are  clearly  established,  it  is  to  Edward 
Jenner,  a  modest  country  doctor  of  Berkeley,  in  the  county  of  Glou- 
cester, England,  that  the  merit  of  demonstrating  the  protective  power 
of  cow-pox  against  small-pox,  and  of  diffusing  a  knowledge  of  this 
fact,  is  due.  Jenner  had  his  attention  directed  to  the  asserted  pro- 
tection conferred  by  cow-pox  during  the  period  of  his  apprentice- 
ship. After  a  residence  in  London  as  a  pupil  of  John  Hunter,  he 
returned  to  the  country  to  practice  his  profession.  About  the  year 
1776  he  began  studying  the  question,  and  gathering  evidence  of  the 
protection  afforded  against  small-pox  by  the  accidental  inoculation  of 
cow-pox  virus.  For  twenty  years  he  studied  the  subject,  patiently 
awaiting  an  opportunity  to  put  his  belief  to  the  test  of  experiment. 
On  the  14th  of  May,  1796,  he  made  his  first  vaccination  on  a  boy 
named  James  Phipps.  Six  weeks  later  he  inoculated  this  boy  with 
variolous  matter,  but  without  success,  no  small-pox  resulting.  Two 
years  later  he  published  his  pamphlet,  entitled  "An  Inquiry  into  the 
Causes  and  Effects  of  the  Variola  Vaccinae,"  etc.,  in  which  he  detailed 
his  observations  and  experiments.  This  publication  produced  a  great 
sensation  in  the  medical  world,  and,  although  much  opposition  was 
at  first  manifested  towards  his  views,  he  soon  gained  many  adherents. 

Vaccination,  as  the  operation  for  the  inoculation  of  cow-pox  virus 
is  termed,  was  rapidly  introduced  into  all  civilized  countries,  and  soon 
demonstrated  its  good  effects  by  greatly  restricting  the  prevalence  of 
small-pox.  It  is  generally  believed  that  the  first  one  to  practice  vac- 
cination in  this  country  was  Dr.  Benjamin  Waterhouse,  of  Boston, 
in  the  summer  of  1800;  but  Dr.  John  E.  Quinan  has  recently  shown^^ 
that  vaccination  was  introduced  into  Maryland,  by  Dr.  John  Craw- 
ford and  Dr.  James  Smith,  at  least  as  early  as  the  date  generally  as- 
signed for  its  introduction  into  Massachusetts. 

It  was  believed  by  Dr.  Jenner,  and  afterward  conclusively  shown 
by  a  number  of  distinguished  experimenters,  that  vaccinia,  as  the  dis- 
ease produced  by  cow-pox  inoculation  was  called,  was  merely  a  modi- 

"  London  Lancet,  September   13,   1862. 
^Quinan,  Joe.  cit.,  pp.  118,  131. 


SMALL-POX.  403 

fication  of  small-pox  as  it  existed  in  the  cow.  Small-pox  virus,  when 
inoculated  upon  the  cow,  produced  cow-pox;  but  the  latter,  re-inocu- 
lated upon  man,  produced  cow-pox  (vaccinia),  and  not  small-pox. 
These  experiments,  however,  have  not  been  successful  in  all  instances, 
and  the  identity  of  the  two  diseases,  while  generally  recognized,  is 
not  absolutely  established.  Sheep-pock  and  horse-pock,  or  "grease," 
are  probably  merely  modifications  of  the  disease  produced  by  inocu- 
lating small-pox  into  those  animals. 

When  cow-pox  virus  is  successfully  inoculated  into  the  human 
system — that  is,  when  a  person  is  successfully  vaccinated — the  fol- 
lowing local  and  general  symptoms  are  observed : — 

In  the  case  of  a  primary  vaccination,  i.e.,  where  the  individual 
has  not  been  previously  vaccinated  or  attacked  by  small-pox,  the  point 
where  the  vaccination  is  made  shows  no  particular  change  for  the 
first  two  days.  If  the  vaccination  is  successful,  a  small,  reddish  pap- 
ule appears  by  the  third  day,  which,  by  the  fifth  or  sixth  day,  has  be- 
come a  distinct  vesicle  of  a  bluish-white  color,  with  a  raised  edge  and 
a  peculiar,  central,  cup-like  depression  called  the  umbilication.  By 
the  eighth  day  this  vesicle  has  become  plump,  round,  and  pearl-col- 
ored, the  central  umbilication  being  still  more  marked.  At  this  time 
a  red,  inflamed  circle,  called  the  areola,  appears,  surrounding  the 
vesicle  and  extending  usually  in  a  radius  of  from  one-half  to  two 
inches  when  fully  developed.  This  inflammatory  ring  is  pretty  firm, 
and  there  is  more  or  less  general  fever  and  often  enlargement  and 
tenderness  of  the  axillary  glands.  After  the  tenth  day  the  areola 
begins  to  fade,  and  the  contents  of  the  vesicle  dry  into  a  hard,  brown- 
ish crust  or  scab,  which  falls  off  between  the  twentieth  and  twenty- 
fourth  days,  leaving  a  punctated  scar,  which  gradually  becomes  white. 

When  the  vaccinia  has  passed  through  all  of  these  stages,  espe- 
cially if  the  vesicle  filled  with  pearly  lymph,  and  the  areola  have  been 
well  developed,  the  vaccination  may  be  considered  a  success,  and  the 
individual  protected  against  small-pox  for  a  number  of  years,  if  not 
for  life.  Eecently  the  doctrine  has  been  strongly  advocated  that  vac- 
cination is  not  absolutely  protective  until  a  subsequent  inoculation 
of  vaccine  fails  to  "take."  According  to  this  view,  vaccination  should 
be  repeated  until  it  fails  any  longer  to  exhibit  any  local  reaction. 
When  this  has  been  attained  the  individual  may  be  considered  abso- 
lutely protected  for  life.  Theoretically,  this  view  has  much  in  its 
favor,  but  there  is,  as  yet,  not  sufficient  evidence  to  establish  it  as  a 
law. 

It  may  be  stated  as  an  established  fact  that  vaccination,  although 


404  TEXT-BOOK  OF  HYGIENE. 

carefully  performed  and  successful,  does  not  confer  absolute  immu- 
nity from  small-pox  for  life.  The  protective  power  seems  to  wear 
out  after  a  time  and  the  individual  then  again  becomes  susceptible 
to  small-pox.  An  attack  of  small-pox  in  a  vaccinated  individual  is, 
however,  nearly  always  much  milder  than  where  there  had  been 
no  vaccination.  There  is  no  fact  in  the  entire  range  of  medicine  bet- 
ter established  than  this:  that  small-pox  in  vaccinated  persons  is  a 
much  less  dangerous  disease  than  typhoid  fever,  while  in  unvaccinated 
cases  the  mortality  ranges  from  30  to  40  per  cent.  An  approximate 
guide  to  the  beneficent  influence  of  vaccination  upon  the  mortality 
from  small-pox  is  furnished  by  a  table  in  Seaton's  report  on  vaccina- 
tion. Before  the  introduction  of  vaccination  the  mortality  from 
small-pox  per  million  of  inhabitants  of  England,  was  nearly  3000  per 
year.  After  the  introduction  of  vaccination  the  mortality  was  re- 
duced to  310  per  million  per  year. 

The  most  remarkable  and  convincing  statistical  evidence  on  the 
question  is  given  by  Drs.  Seaton  and  Buchanan,  of  England.  Dur- 
ing the  small-pox  epidemic  in  London,  in  1863,  they  examined  over 
50,000  school-children,  and  found  among  every  thousand  without  evi- 
dence of  vaccination  360  with  scars  of  small-pox,  while  of  every 
thousand  presenting  some  evidence  of  vaccination  only  1.78  had  any 
such  traces  of  small-pox  to  exhibit.^^  The  reliability  of  general  mor- 
tality statistics  may  be  called  in  question — in  some  cases,  with  justice ; 
but  the  significance  of  these  figures  cannot  be  evaded. 

The  upper  and  outer  surface  of  the  arm  is  usually  chosen  as  the 
point  where  the  virus  is  inserted,  although  any  part  of  the  body  which 
can  be  protected  against  friction,  or  other  mechanical  irritation,  may 
be  selected.  The  method  varies  slightly  in  the  hands  of  different 
vaccinators.  The  two  methods  most  frequently  in  use  are  scarifica- 
tion and  erasion.  The  former  method  has  the  indorsement  of  Mr. 
Seaton,  the  high  English  authority.  The  method  of  erasion — scrap- 
ing off  the  epidermis  until  the  papillary  layer  of  the  skin  is  laid 
bare — is  now  most  frequently  used  in  this  country.  The  best  instru- 
ment to  use  is  a  clean  thumb-lancet;  in  default  of  this,  an  ordinary 
sewing-needle  answers  well.  Where  animal  vaccine  is  used,  the  ivory 
slip  or  sharpened  quill  may  also  be  used  with  satisfaction  to  make  the 
scarification  or  erasion.  Whatever  instrument  is  used,  it  should  always 
be  kept  perfectly  clean. 

A  point  of  vital  importance  is  that  which  relates  to  the  proper 


"Seaton,  "Vaccination,"  ii  Reynold's  System  of  Medicine,  vol.  i,  p.  291. 
Second  edition. 


SMALL-POX.  405 

age  at  which  children  should  be  vaccinated.  Ordinarily,  vaccina- 
tion should  be  performed  within  the  first  six  months  of  life.  In  time 
of  danger  from  a  threatened,  or  in  the  presence  of  an  actual,  epidemic, 
infants  may  be  vaccinated  when  only  one  day  old. 

In  order  to  secure  permanent  protection  against  small-pox,  re- 
vaccination  should  be  performed  after  a  certain  interval.  Some  place 
the  period  at  which  this  second  vaccination  should  be  done  at  five 
years,  while  others  allow  a  longer  interval — seven,  eight,  or  ten  years. 
The  law  of  Prussia  is  that  every  child  that  has  not  already  had  small- 
pox must  be  vaccinated  within  the  first  year  of  its  life,  and  every 
pupil  in  a  public  or  private  institution  is  to  be  revaccinated  during 
the  year  in  which  his  or  her  twelfth  birthday  occurs. 

This  law  was  passed  in  1874.  Prior  to  this  time  the  mortality 
from  small-pox  was  15  to  20  per  100,000  of  the  population.  Since 
the  law  was  enacted  the  small-pox  mortality  has  varied  from  0.3  to 
3.6  per  10,000.  Not  a  single  death  from  small-pox  occurred  in  the 
German  army  between  1874  and  1882.^* 

A  revaccination,  even  if  successful,  seldom  passes  through  all  the 
typical  stages  of  a  primary  vaccination.  The  vesicle  rarely  becomes 
so  full  and  plump,  and  is  more  frequently  flat  and  irregular  in  outline. 
Swelling  of  the  axillary  glands  and  other  complications  alsQ  seem 
to  be  more  frequent  than  in  cases  where  the  vaccination  is  done  for 
the  first  time. 

The  question  whether  the  lymph  direct  from  the  cow  or  human- 
ized lymph  is  the  more  efficient  has  caused  much  discussion.  The 
objections  urged  against  the  use  of  humanized  virus  are :  first,  that 
its  protective  power  has  become  diminished  by  transmission  through 
many  generations;  second,  that  it  is  liable  to  transmit  other  diseases, 
such  as  syphilis,  tuberculosis,  scrofula,  etc. ;  third,  that  it  is  fre- 
quently difficult  to  obtain  in  sufficient  quantities  in  an  emergency, 
such  as  an  actual  or  threatened  epidemic. 

The  first  objection  is  disproved  by  the  testimony  of  many  of  the 
most  distinguished  medical  men  in  Europe  and  this  country.  Hu- 
manized vaccine  virus,  when  properly  inoculated,  seems  to  be  as 
completely  protective  against  small-pox  as  that  taken  direct  from 
the  animal.  Among  its  advantages  are,  that  it  "takes"  more  readily 
and  runs  through  its  stages  of  development  in  a  shorter  time,  and 
that  it  will  retain  its  active  properties  for  a  greater  length  of  time 
than  animal  virus.  The  physician  can  usually  control  the  source 
whence  he  obtains  it.    He  can  watch  over  the  subject  that  furnishes  it 

'■"rrolich,  Militilr-Medicin,  p.  461. 


406  TEXT-BOOK  OF  HYGIENE. 

and  reject  that  which  is  suspicious.  With  humanized  lymph  col- 
lected by  the  physician  himself  there  can  be  no  doubt  as  to  its  purity 
or  age;  with  animal  Ijonph  furnished  by  the  cultivators  of  that  ar- 
ticle there  can  be  no  certainty  about  either  of  these  important  points. 

That  syphilis  has  been  inoculated  with  humanized  virus  can  no 
longer  be  open  to  doubt.  The  recent  experiment  of  Dr.  Cory,  of 
England,  has  settled  this  question  definitely.  With  care,  however, 
this  sad  accident  can  easily  be  avoided,  and  the  fact  that  syphilis 
has  been  so  rarely  transmitted  by  vaccination  is  sufficient  evidence  that 
the  danger  of  such  infection  is  not  very  great. 

The  most  serious  objection  against  the  exclusive  use  of  human- 
ized lymph,  is,  that  in  grave  emergencies,  such  as  a  rapidly-spreading 
epidemic  of  small-pox,  it  is  difficult  to  obtain  a  sufficient  supply  of 
the  lymph.  However,  humanized  virus  can  never  be  obtained  under 
the  same  strict  asepsis  as  prevails  in  the  production  of  animal  virus, 
and  its  employment  is  not  justifiable  on  this  account,  if  for  no  other 
reason. 

Humanized  virus  is  inoculated,  either  in  the  fresh  state,  i.e.,  the 
lymph  is  taken  directly  from  the  vesicle  on  the  seventh  day  and  inoc- 
ulated directly  into  the  arms  of  other  individuals,  or  else  the  vesicle 
is  allowed  to  dry  into  a  crust,  with  which  a  thin  paste  is  made  by 
moistening  with  water  at  the  time  of  vaccination.  The  readiest  way 
of  using  the  crust  is  to  crush  a  small  fragment  between  two  small 
squares  of  glass,  then  moistening  it  with  a  drop  of  warm  (not  hot) 
water,  and  smearing  it  on  the  spot  where  the  vaccination  is  to  be  made. 
With  a  lancet  a  number  of  cross-scarifications  are  then  made,  and  the 
virus  well  rubbed  in.  Only  so  much  of  the  crust  should  be  moistened 
as  will  be  used  at  the  time.  Particular  care  must  be  taken  not  to  use 
saliva  for  moistening  the  crust.  Aside  from  being  unclean,  there  is 
danger  of  producing  blood-poisoning  by  inoculating  certain  of  the 
oral  secretions. ^^ 

Animal  virus  is  obtained  by  inoculating  a  calf  or  heifer  with 
virus  from  another  case  of  cow-pox,  or  by  re-inoculating  humanized 
vaccine  virus  into  the  animal.  The  vesicles  are  opened  on  the  sev- 
enth day  or  at  the  end  of  ninety-six  hours  (Copemann)  and  ivory 
points  or  the  ends  of  quills  coated  with  the  Ijmiph  and  dried  with  a 
gentle  heat,  or  the  pulp  is  rubbed  up  with  50  per  cent,  glycerin  and 
drawn  up  in  fine  glass  tubes.  The  whole  operation,  from  beginning 
to  end,  is  done  under  strict  asepsis. 

In  vaccinating  with  animal  virus,  the  quill  or  ivory  point  is  first 

i^See  Sternberg  and  Magnin,  Bacteria,  p.  355.     Second  edition. 


SMALL-POX.  407 

moistened  with  a  drop  of  water  to  soften  the  adhering  lymph;  the 
scarification  or  abrasion  of  the  skin  is  then  made  with  the  lancet  or 
needle,  and  the  virus  rubbed  well  into  the  scarified  spot,  or,  in  using 
the  giycerinized  virus,  the  latter  is  simply  rubbed  into  the  scarified 
area. 

In  using  animal  virus  the  successive  stages  of  development  are 
usually  one  or  two  days  later  than  when  humanized  virus  is  used. 
In  the  former  case  the  areola  is  rarely  developed  before  the  ninth  day. 

Certain  complications  are  likely  to  occur  in  the  course  of  the 
vaccinia,  of  which  the  student  should  be  aware. 

When  the  areola  appears  there  is  usually  more  or  less  fever. 
Sometimes  the  constitutional  manifestations  are  decidedly  marked, 
fever  of  a  high  grade  being  not  uncommon.  In  addition  to  the 
glandular  enlargement  and  tenderness,  an  outbreak  of  roseola  some- 
times comes  on  about  the  ninth  or  tenth  day.  This  eruption  may  be 
mistaken  for  scarlet  fever,  but  if  it  is  remembered  that  two  infectious 
diseases  rarely  co-exist  in  one  individual  during  their  full  develop- 
ment this  error  will  be  avoided. 

Erysipelas  involving  the  entire  arm  is  sometimes  observed  as  a 
complication  of  vaccination.  This,  in  nearly  every  case,  depends  upon 
some  depravement  of  the  patient's  constitution,  malnutrition,  bad 
sanitary  surroundings,  or,  perhaps,  more  frequently,  chronic  alco- 
holism. Individuals  who  are  habitually  intemperate  in  the  indulgence 
of  alcoholic  liquors  are  especially  unfavorable  subjects  for  vaccination. 
The  results  are,  fortunately,  rarely  serious  to  the  patient. 

Another  inconvenient  complication  of  vaccination  is  the  forma- 
tion of  a  deep,  ill-looking,  sloughing  ulcer  at  the  vaccinated  point. 
This  is  the  result  of  infection  with  impure  virus  or  lack  of  cleanliness 
in  making  the  scarification.  It  should  be  borne  in  mind  that  a  very 
sore  arm,  especially  if  followed  by  the  formation  of  an  ulcer  or  gan- 
grenous sore,  may  not  be  protective  against  small-pox.  Such  a  patient 
should  not  be  considered  properly  vaccinated,  and  must  be  revaccin- 
ated  as  soon  as  he  recovers,  or  immediately  if  there  is  any  danger 
of  small-pox  infection. 

Children  with  eczematous  eruptions,  however,  localized  upon  any 
portion  of  the  body,  should  not  be  vaccinated  until  the  eruption  is  first 
cured,  except  in  times  of  danger  from  small-pox.  The  eczema  will 
be  almost  certainly  rendered  worse  in  consequence  of  the  general 
hyperemia  accompanying  the  febrile  reaction,  and  the  physician  who 
performs  the  vaccination  will  be  blamed  for  causing  the  skin  disease. 


408  TEXT-BOOK  OF  HYGIENE. 

The  author  has  placed  on  record^''  two  cases  of  general  psoriasis 
following  vaccination,  and  other  cases  have  been  since  reported. 
Urticaria  and  exudative  erythema  have  also  been  repeatedly  observed. 

As  before  stated,  syphilis  may  be  communicated  to  the  vaccines 
by  vaccine  virus  obtained  from  a  syphilitic  subject,  but  this  acci- 
dent is  infrequent.  There  can  be  little  doubt  that  some  of  the  cases 
reported  as  "vaccinal  syphilis"  are  cases  of  tardy  hereditary  syphilis, 
lighted  up  by  the  general  systemic  disturbance  following  vaccination. 
In  some  cases  tetanus  has  followed  vaccination.  This  unfortunate 
complication  may  be  due  either  to  the  tetanus  bacilli  gaining  access 
to  the  virus  in  the  process  of  preparation,  or  infection  of  the  patient 
during  vaccination. 

Next  in  importance  to  vaccination  in  the  prophylaxis  of  small- 
pox is  prompt  isolation  of  the  sick.  No  one  but  the  medical  and  other 
attendants  of  the  sick  should  be  allowed  to  come  in  contact  with  them. 
All  attendants  and  other  persons  exposed  to  the  infection  should, 
of  course,  be  promptly  vaccinated,  unless  this  has  been  successfully 
done  within  the  previous  year  or  two.  Disinfection  of  all  discharges 
from  the  patient  and  of  the  room  and  its  contents,  after  the  patient 
has  recovered  or  died,  must  be  practiced.  The  best  disinfectants  in 
small-pox  are  bichloride  of  mercury,  free  chlorine,  sulphurous  acid, 
and  formaldehyde. 

When  it  is  learned  that  a  person  has  small-pox,  if  he  is  not  re- 
moved to  a  special  hospital,  a  room  should  be  prepared  for  his  occu- 
pancy. The  carpets  should  be  taken  up  and  the  floor  kept  clean. 
Window-curtains  and  unnecessary  furniture  and  drapery  should  be  re- 
moved from,  the  room.  After  recovery  of  the  patient  the  bed-clothing 
must  be  thoroughly  disinfected  with  steam  or  sulphurous  acid,  or  de- 
stroyed by  fire.  The  individual  himself  should  not  be  allowed  to 
mingle  with  healthy  persons  until  all  danger  of  infection  is  passed 
and  the  surface  of  his  body  has  been  thoroughly  disinfected. 

At  a  conference  of  sanitary  officials  in  the  city  of  Chicago  (May, 
1894)  the  following  propositions  were  adopted.  They  represent  the 
most  advanced  conclusions  of  competent  authority  upon  the  most 
practical  means  of  limiting  the  spread  of  sroall-pox : — 

"1.  The  city  should  be  divided  into  districts  containing  not  more 
than  10,000  people. 

"2.  Each  district  should  be  placed  under  the  supervision  of  a 
competent  medical  inspector  with  necessary  assistants  to  (a)  make 
a   house-to-house   inspection;     (h)    to   successfully   vaccinate,   within 

"Journal  Cutaneous  and  Venous  Diseases,  vol.  i,  No.  1,  p.  11. 


ASIATIC  CHOLERA.  409 

the  shortest  possible  time,  all  persons  who  have  not  been  vaccinated 
during  the  outbreak,  and  that  the  first  vaccination  be  within  seven 
days;  (c)  to  properly  disinfect  all  houses  and  their  contents  where 
small-pox  occurs. 

"3.  Necessary  means  and  appliances  for  efficient  disinfection  of 
materials,  premises,  etc.,  should  be  provided  as  the  exigencies  of  each 
district  may  require. 

"4.  Each  case  of  small-pox  should  be  immediately  removed  to  a 
suitably  constructed  and  properly  equipped  and  officered  isolation 
hospital. 

"5.  Except  in  extreme  cold  weather,  hospital  tents,  as  prescribed 
in  the  United  States  Army  Regulations,  floored  and  warmed,  are  pre- 
ferable to  the  average  hospital  or  private  dwelling,  and  increase  the 
chances  of  recovery  of  the  patients.  Cases  of  small-pox  necessarily^ 
detained  in  their  own  homes  should,  with  their  attendants,  be  rigidly 
isolated  during  the  period  of  danger,  and  physicians  visiting  such 
patients  professionally  shall  be  subject  to  such  regulations  as  may  be 
prescribed  by  the  local  health  officer. 

"6.  Persons  exposed  to  small-pox  contagion  should  be  immedi- 
ately vaccinated  or  revaccinated,  and  kept  imder  observation  for  not 
less  than  fourteen  days  from  time  of  last  exposure. 

"7.  It  is  the  sense  of  this  conference  that  where  such  measures 
are  all  enforced  it  will  net  be  necessary  for  neighboring  cities  and 
states  to  exclude  all  persons  who  come  from  such  city  who  are  not 
protected  against  small-pox  by  vaccination,  and  to  require  disinfec- 
tion of  all  baggage  and  merchandise  capable  of  conveying  small-pox 

infection.^' 

ASIATIC   CHOLERA. 

A  disease  which  causes  the  death  of  three-fourths  of  a  million  of 
human  beings  where  it  is  endemic  within  the  space  of  flve  years,  and 
which  makes  periodical  excursions,  spreading  over  nearly  the  entire 
inhabited  globe  with  destructive  violence,  must  surely  command  the 
interested  attention  of  every  intelligent  person.  Asiatic  cholera  is 
endemic  in  India,  where  it  probably  originated  centuries  ago.  Some 
authors  claim  to  have  found  satisfactory  evidence  of  its  existence  in 
the  writings  of  the  classical  authors  of  India  and  Greece  at  a  period 
as  early  as  the  second  century  of  the  Christian  era.  The  evidence  is, 
however,  not  beyond  question.  In  the  sixteenth  and  seventeenth  cen- 
turies European  travelers  in  the  East  gave  pretty  exact  accounts  of 
the  disease.  One  of  the  most  definite  of  these  was  given  by  Gaspar 
Correa,  an  officer  in  Vasco  de  Gamma's  expedition  to  Calicut.     He 


410  TEXT-BOOK  OF  HYGIENE. 

states  that  Zamorin,  the  chief  of  Calicut,  lost  20,000  of  his  troops 
by  the  disease.  A  still  more  definite  and  the  first  trustworthy  account 
is  that  of  Sonnerat,  a  French  traveler.  He  describes  a  pestilence  hav- 
ing all  the  characters  now  recognized  as  belonging  to  Asiatic  cholera,- 
which  prevailed  in  the  neighborhood  of  Pondicherry  and  the  Coro- 
mandel  coast  in  1768  and  1769,  and  which  carried  off  60,000  of  those 
attacked  by  it  within  a  year.  Dr.  McPherson,  in  his  "History  of 
Cholera,^'  gives  numerous  references  which  indisuptably  establish  the 
endemic  existence  of  the  disease  in  India  prior  to  the  present  cen- 
tury. 

Being  endemically  prevalent  over  a  greater  or  less  area  of  India 
for  many  years,  cholera  finally,  in  1817,  crossed  the  boundaries  of  that 
country,  and,  advancing  in  a  southeasterly  direction,  invaded  Ceylon 
and  the  Sunda  Islands  in  1818.  In  a  westerly  direction  the  disease 
was  carried  to  the  islands  of  Mauritius  and  Eeunion,  and  reached  the 
African  coast  in  1820.  During  this  year  it  also  traveled  northeasterly, 
devasting  the  Chinese  Empire  for  the  two  following  years,  reach- 
ing Nagasaki,  in  Japan,  in  1822. 

In  1821  the  disease  spread  from  India  in  a  westerly  direction, 
extending  along  the  east  coast  of  Arabia  to  the  border  of  Mesopotamia 
and  Persia.  In  the  spring  of  1822  it  began  with  renewed  violence, 
following  the  river  Tigris  to  Kurdistan,  and,  extending  farther  in  a 
westerly  direction,  reached  the  Mediterranean  coast  of  Syria.  In 
the  following  year,  1823,  it  extended  from  Persia  into  Asiatic  Eussia, 
reaching  Astrachan  on  the  European  border  in  September,  but  dying 
out  nearly  everywhere  beyond  the  borders  of  India  during  the  ensuing 
winter. 

In  1826  cholera  again  advanced  from  India,  reaching  Orenburg 
in  Eussia,  in  1829,  and  in  the  following  winter  appeared  in  St.  Peters- 
burg. Extending  to  the  north  and  south,  it  invaded  Finland  and 
Poland  the  same  year.  From  Persia  the  disease  spread  to  Egypt  and 
Palestine  in  1830-31. 

From  Eussia  the  pestilence  invaded  Germany  in  1831,  passing 
thence  in  1832  into  France,  the  British  Isles,  Belgium,  the  ISTether- 
lands,  Norway,  and  Sweden.  In  the  latter  year  cholera  crossed  the 
Atlantic  Ocean  for  the  first  time,  being  carried  to  Canada  by  emi- 
grants from  Ireland,  and  spreading  thence  to  the  United  States  by 
way  of  Detroit.  In  the  same  j^ear  it  was  imported  into  New  York  by 
emigrants,  and  rapidly  spread  along  the  Atlantic  coast.  During  the 
winter  of  1832  it  appeared  at  Few  Orleans,  and  passed  thence  up  the 
Mississippi  Valley.     Extending  into  the  Indian  country,  causing  sad 


ASIATIC  CHOLERA.  411 

havoc  among  the  aborigines,  it  advanced  westward  until  its  further 
progress  was  stayed  by  the  shores  of  the  Pacific  Ocean.  In  1834  it 
reappeared  on  the  east  coast  of  the  United  States,  but  did  not  gain 
much  headway,  and  in  the  following  year  New  Orleans  was  again  in- 
vaded by  way  of  Cuba.  It  was  imported  into  Mexico  in  1833.  In 
1835  it  appeared  for  the  first  time  in  South  America,  being  restricted, 
however,  to  a  mild  epidemic  on  the  Guiana  coast. 

While  the  pestilence  was  advancing  in  the  Western  Hemisphere, 
it  also  spread  throughout  Southern  Europe,  invading,  in  turn,  Portu- 
gal, Spain,  and  Italy. 

Extending  in  an  easterly  direction  from  India,  the  disease  reached 
China  and  Japan  in  1830-31;  westwardly,  Africa  was  invaded  in 
1834,  and  ravaged  by  the  epidemic  during  the  following  three  years. 

This  second  extensive  outbreak  of  cholera  ended  in  1837,  disap- 
pearing at  all  points  beyond  the  borders  of  India.  In  1846  the  dis- 
ease again  advanced  beyond  its  natural  confines,  reaching  Europe, 
by  way  of  Turkey,  in  1848.  In  the  autumn  of  this  year  it  also  ap- 
peared in  Great  Britain,  Belgium,  the  Netherlands,  Sweden,  and  the 
United  States,  entering  by  way  of  New  York  and  New  Orleans.  In 
the  succeeding  two  years  the  entire  extent  of  country  east  of  the  Eocky 
Mountains  was  invaded.  During  1851  and  1852  the  disease  was  fre- 
quently imported  by  emigrants,  who  were  annually  arriving  in  great 
numbers  from  the  various  infected  countries  of  Europe.  In  1853  and 
1854,  cholera  again  prevailed  extensively  in  this  country,  being,  how- 
ever, traceable  to  renewed  importation  of  infected  material  from 
abroad.  In  the  following  two  years  it  also  broke  out  in  numerous 
South  American  States,  where  it  prevailed  at  intervals  until  1863. 

Hardly  had  this  third  great  pandemic  come  to  an  end  before  the 
disease  again  advanced  from  the  Ganges,  spreading  throughout  India, 
and  extending  to  China,  Japan,  and  the  East  India  Archipelago  during 
the  years  1863  to  1865.  In  the  latter  year  it  reached  Europe  by  way 
of  Malta  and  Marseilles.  It  rapidly  spread  over  the  Continent,  and 
in  1866  was  imported  into  this  country  by  way  of  Halifax,  New  York, 
and  New  Orleans.  This  epidemic  prevailed  extensively  in  the  West- 
ern States,  but  produced  only  slight  ravages  on  the  Atlantic  coast, 
being  kept  in  check  by  appropriate  sanitary  measures.  In  the  same 
year  (1866)  the  disease  was  also  carried  to  South  America,  and  in- 
vaded, for  the  first  time,  the  States  bordering  on  the  Rio  de  la  Plata 
and  the  Pacific  coast  of  the  Continent. 

WHiile  the  epidemic  was  thus  advancing  westward  from  its  home 
in  India,  it  was  at  the  same  time  spreading  northwardly  over  the  en- 


412  TEXT-BOOK  OF  HYGIENE, 

tire  western  part  of  Asia,  and  in  a  southeasterly  direction  over  North- 
ern Africa.    In  the  latter  continent  it  prevailed  from  1865  to  1869. 

Cholera  never  entirely  disappeared  in  Eussia  during  the  latter 
half  of  the  sixth  decade,  and  in  1870  it  again  broke  out  with  vio- 
lence, carrying  off  a  quarter  of  a  million  of  the  inhabitants  before 
dying  out  in  1873.  It  spread  from  Eussia  into  Germany  and  France, 
and  was  imported,  in  1873,  into  this  country,  entering  by  way  of  New 
Orleans  and  extending  up  the  Mississippi  Valley.  None  of  the 
Atlantic-coast  cities  suffered  from  the  epidemic  in  1873,  and  since  that 
year  the  United  States  have  been  entirely  free  from  the  disease,  with 
the  exception  of  a  few  imported  cases  in  New  York  Harbor  in  1887. 

In  June,  1883,  a  new  epidemic  of  cholera  broke  out  in  Egypt, 
where  it  raged  with  great  violence.  The  disease  first  appeared  in 
Damietta,  near  the  outlet  of  the  Suez  Canal.  It  was  unquestionably 
imported  from  India,  probably  Bombay,  where  it  j^revailed  as  early  as 
the  month  of  May.  At  the  time  of  the  outbreak  in  Damietta  that 
city  was  overcrowded  with  people  who  had  come  to  attend  a  great  re- 
ligious fair  and  festival.  It  has  been  proven  that  pilgrims  from  Bom- 
bay were  among  the  attendants  at  this  fair.  The  epidemic  came  to 
an  end  in  Egypt  in  the  autumn  of  1883.  In  the  same  year  (1883)  a 
small  outbreak  occurred  in  Marseilles,  but  intelligence  of  it  was  care- 
fully suppressed  by  the  authorities.  The  disease  does  not  seem  to  have 
spread  from  this  centre,  but  in  June  of  the  following  year  cholera 
broke  out  in  Toulon,  having  probably  been  imported  in  a  transport 
ship  returning  from  Tonquin.  This  outbreak  was  very  violent  and 
rapidly  spread  throughout  Southern  France,  Italy,  and  Spain.  After 
apparently  dying  out  during  the  winter,  it  reappeared  in  the  spring  of 
1885  with  renewed  violence.  The  total  number  of  cases  in  Spain  alone 
in  the  latter  year  was  over  one-third  of  a  million,  with  nearly  120,000 
deaths. 

In  the  summer  of  1885  cholera  also  broke  out  in  a  virulent  form 
in  Japan,  and,  after  a  cessation  during  the  following  winter,  recurred 
with  increased  fatality  in  1886.  In  the  latter  year  there  were  over 
100,000  deaths  from  the  disease  in  that  country. 

During  1886  and  1887  cholera  continued  in  Southeastern  Italy 
and  in  the  Austrian  dominions  at  the  head  of  the  Adriatic.  A  few 
cases  occurred  in  France  and  Germany,  but  by  stringent  sanitary  meas- 
ures an  epidemic  was  averted. 

In  November,  1886,  cholera  was  carried  to  South  America  in  an 
Italian  sliip,  the  ^'Perseo,"  bound  from  Genoa  to  Buenos  Ayres.  The 
disease  rapidly  spread  in  the  Argentine  Eepublic,  and,  crossing  the. 


ASIATIC  CHOLERA.  413 

Andean  range,  invaded  the  Pacific  coast  of  the  South  American  con- 
tinent for  the  second  time,  reaching  Chili  and  Bolivia  and  threatening 
Peru  and  Brazil.  In  Chili  alone  there  were  over  10,000  deaths  in  the 
first  six  months  of  1887.  The  further  progress  of  the  epidemic  was 
arrested  and  the  entire  Western  Hemisphere  is  now  free  from  the 

disease. 

Prom  July  to  December,  1889,  cholera  prevailed  with  consider- 
able virulence  in  Mesopotamia.  In  1890  it  reappeared  in  Spain;  in 
1893  in  France  and  Germany,  raging  with  great  violence  in  Ham- 
burg. Nearly  8000  persons  died  from  the  disease  in  the  latter  city. 
Some  cases  were  brought  thence  to  New  York,  but  the  active  sanitary 
measures  taken  were  successful  in  preventing  its  further  spread. 

This  brief  historical  sketch  of  all  the  epidemics  of  cholera  ob- 
served beyond  the  borders  of  India  demonstrates  several  facts :  first, 
that  the  home  or  breeding-place  of  cholera  is  in  India,  especially  the 
delta  of  the  Ganges,  whence  it  spreads  at  intervals  throughout  the 
world;  second,  that  it  always  advances  along  the  lines  of  travel  of 
large  bodies  of  human  beings ;  and  third,  that  it  advances,  by  pre- 
ference, along  water-routes.  Exceptions  undoubtedly  occur,  but  the 
rule  is. a  general  one.  The  disease  seems  to  spread  with  difficulty  along 
the  lines  of  railroad.  When  the  disease  has  extended  from  New 
Orleans  it  has  always  been  up  the  Mississippi  Valley,  expending  its 
violence  upon  the  river  cities— Vicksburg,  Memphis,  St.  Louis,  and 
Cincinnati. 

Several  factors  must  concur  before  there  can  be  an  epidemic  of 
cholera.  These  are :  first,  the  cholera  poison ;  second,  certain  local 
conditions  of  air,  soil,  or  water;  and,  third,  individual  predisposition. 
Without  a  concurrence  of  all  these  conditions  no  outbreak  can  occur. 
If,  by  any  means,  the  co-existence  of  these  three  conditions  can  be 
prevented,  cholera  can  be  averted.  The  following  are  facts  bearing 
upon  this  question:  Cholera  is  communicated  through  the  agency 
of  a  specific  poison.  This  does  not  admit  of  doubt.  The  researches 
of  Dr.  Eobert  Koch,  of  Germany,  have  established  the  fact  that  a 
micro-organism  found  in  the  intestinal  discharges  of  cholera  pa- 
tients and  in  the  bodies  of  those  dead  with  the  disease  is  the  active 
agent  in  propagating  the  malady.  This  organism,  named  by  Koch 
the  "comma  bacillus,"  from  its  general  resemblance  to  a  comma,  was 
first  discovered  by  this  eminent  pathologist  in  the  intestinal  contents 
of  cholera  corpses  in  Egypt,  in  1883,  and  in  the  following  year  more 
thoroughly  studied  in  Calcutta,  whither  he  had  been  sent  by  the 
Gorman  government  to  pursue  his  investigations.     It  has  been  dem- 


414  TEXT-BOOK  OF  HYGIENE. 

onstrated  that  this  germ  is  always  present  in  the  discharges  of  cholera 
patients,  and  up  to  this  time  it  has  not  been  found  in  any  other  dis- 
ease. Experiments  upon  animals  have  also  shown  that  cholera  can 
be  produced  in  the  latter  by  introducing  the  germ  into  their  bodies 
in  various  ways.  The  demonstration  of  the  bacterial  nature  of 
cholera  seems  to  be  complete. 

While  cholera  cannot  be  regarded  as  personally  contagious  in  the 
same  sense  or  in  the  same  degree  as  small-pox,  there  can  be  no  doubt 
that  it  is  spread  only  by  the  poison  from  other  cases  of  the  disease. 
Generally  this  disease  is  conveyed  by  water  polluted  by  the  dejections 
of  cholera  patients.  The  regularity  of  its  march  along  routes  by 
which  the  intercourse  of  human  beings  takes  place,  and  always  in 
connection  with  other  cases  of  cholera,  proves  this.  There  is  no  un- 
doubted case  on  record  where  genuine  cholera  has  been  spontane- 
ously developed  outside  of  India. 

That  certain  geological  and  perhaps  meteorological  conditions 
are  necessary  for  the  propagation  or  virulence  of  the  poison  of 
cholera  is  beyond  dispute.  Outbreaks  usually  take  place  during  the 
summer  or  autumn,  and  nearly  always  partly  or  entirely  die  out  dur- 
ing cold  weather.  Further,  in  nearly  all  epidemics,  certain  cities  or 
towns,  or  portions  of  a  town,  into  which  persons  sick  with  cholera  are 
brought,  and  where  the  poison  of  the  disease  is  thus  imported,  remain 
exempt  from  the  effects  of  the  epidemic.  The  inference  to  be  drawn 
from  this  fact  is  that  in  such  localities  the  local  conditions  are  un- 
favorable to  the  development  of  the  poisonous  germ,  and  it  becomes 
inert. 

In  India  all  the  local  conditions  favorable  to  the  propagation  of 
the  cholera-germ  are  found.  The  filthy  personal  habits  of  the  people, 
the  overcrowding,  the  intense  heat,  the  lack  of  sufficient,  appropriate, 
or  properly-prepared  food,  and  the  extensive  pollution  of  the  water- 
supply,  all  combine  to  produce  the  necessary  conditions  of  develop- 
ment of  the  cause  of  cholera.  These  conditions,  doubtless,  to  a  con- 
siderable extent,  give  rise  to  that  depression  of  the  system  which  seems 
necessary  to  constitute  the  individual  predisposition  to  become 
infected. 

Given,  then,  at  any  place,  a  number  of  persons  of  a  lowered  de- 
gree of  vitality — that  is  to  say,  persons  not  capable  of  resisting  unfa- 
vorable influences  upon  their  health  under  unfavoring  conditions; 
given  conditions  of  climate,  water,  and  soil  more  or  less  similar  to 
those  existing  in  India:  only  the  introduction  of  the  third  factor, 
the  cholera  poison,  is  needed  to  cause  an  outbreak.     In  many  cities 


ASIATIC  CHOLERA.  415 

of  this  country  and  Europe,  as  proven  by  the  epidemics  in  Toulon, 
Marseilles,  Naples,  and  other  cities  of  Italy  and  Spain,  the  condi- 
tions are  present  which  would  furnish  the  most  favorable  breeding- 
place  for  the  cholera-germ  if  introduced. 

The  dejections  and  vomited  matters  of  cholera  patients  contain 
the  active  agent  which  produces  the  disease.  The  contagious  prin- 
ciple contained  in  these  excretions,  the  cholera-germ  or  "comma 
bacillus"  discovered  by  Koch,  may  gain  an  entrance  into  the  body 
through  the  drinking-water  or  through  infected  air.  Probably  both 
modes  are  equally  competent  channels  of  infection.  The  prevailing 
theory  is  that  pollution  of  the  drinking-water  is  the  most  frequent 
source  of  the  rapid  spread  of  the  disease.  A  very  striking  instance 
of  this  occurred  in  London  during  the  epidemic  of  1854,  which  has 
already  been  referred  to,^'^  and  during  the  cholera  epidemic  in  Ham- 
burg in  1893. 

Another  striking  instance  of  the  communication  of  cholera  by 
polluted  water  has  been  reported  by  Mr.  John  Simon,  long  the  chief 
medical  officer  of  the  English  "Local  Government  Board."  The 
facts  are  as  follow:  The  Lambeth  Water  Company  drew  its  supply 
from  the  Thames,  at  Ditton,  above  the  influence  of  the  London  sew- 
age and  the  tidal  flux.  The  Southwark  and  Vauxhall  Company  drew 
its  supply  from  the  river  near  Vauxhall  and  Chelsea.  The  water  of 
the  Lambeth  Company  was  tolerably  pure,  and  that  of  the  South- 
wark and  Vauxhall  Company  was  very  impure.  The  water  of  both 
companies  was  distributed  in  the  same  district  at  the  same  time  and 
among  the  same  class  of  people,  the  pipes  of  the  two  companies  being 
laid  pretty  evenly  in  the  same  areas,  in  many  places  running  side 
by  side  in  the  same  streets,  and  the  houses  supplied  being  pretty 
equally  distributed.  The  deaths  from  cholera  in  the  houses  supplied 
by  the  Lambeth  Company  were  at  the  rate  of  37,  and  in  the  houses 
supplied  by  the  Southwark  and  Vauxhall  Company  at  the  rate  of 
130,  to  every  10,000  persons  living.  It  appears,  therefore,  that  of 
the  drinkers  of  the  foul  water  about  three  and  a  half  times  as  many 
as  those  who  drank  the  pure  water  died  of  cholera. 

Iti  addition  to  the  influence  of  polluted  drinking-water  in  spread- 
ing cholera,  must  be  mentioned  articles  of  food  contaminated  with 
the  infectious  matter  of  the  disease.  It  is  also  no  longer  open  to 
question  that  persons  may  become  infected  by  handling  the  clothing 
and  bedding  of  cholera  patients.  Laundresses  are  in  special  danger 
from  this  source. 


"See  ante,  page  64. 


41g  TEXT-BOOK  OF  HYGIENE. 

The  prophylaxis  against  cholera  comprises  such  measures  as  will 
prevent  the  admission  of  the  cholera-poison  into  a  community,  arrest 
the  development  of  the  poison  after  its  introduction,  and  reduce  the 
individual  susceptibility  to  attack. 

It  is  evident  from  the  foregoing  that  if  the  introduction  of  the 
cholera-poison  could  be  prevented  no  outbreak  of  the  disease  could 
occur.  With  this  in  view,  some  have  urged  the  enforcement  of  a  strict 
policy  of  non-intercourse  with  the  infected  localities.  But  at  the 
present  day  few  sanitarians  advocate  these  extreme  measures.  A 
modified  system  of  restricted  intercourse  is  supported  by  many  au- 
thorities, who  claim  that  by  the  adoption  of  a  thorough  system  of 
maritime  inspection,  disinfection,  and  observation — a  rational  quar- 
antine, in  fact — the  poison  can  be  rendered  ineffective  or  its  entrance 
into  a  community  prevented. 

The  best  authorities,  however,  think  that  it  is  not  only  easier,  but 
far  more  effective  to  place  the  threatened  locality  in  such  a  sanitary 
condition  that  the  development  of  the  cholera-poison  cannot  take 
place.  The  contrast  between  the  effectiveness  of  quarantine  and  local 
sanitation  as  safeguards  against  cholera  has  been  well  expressed  by 
von  Pettenkofer,  who  compares  cholera  epidemics  to  powder  explo- 
sions. The  virus  of  cholera,  he  says,  is  the  spark  that  evades  the 
strictest,  quarantine ;  the  powder  is  the  ensemble  of  local  conditions 
which  predispose  to  the  outbreak.  "It  is  wiser,  therefore,  to  seek 
out  and  remove  the  powder  than  to  run  after  and  try  to  extinguish 
each  individual  spark  before  it  drops  upon  a  mass  of  powder,  and, 
igniting  it,  causes  an  explosion  which  blows  us  into  the  air  with  our 
extinguishers  in  our  hands." 

The  measures  of  sanitation  to  be  enforced  are  such  as  will  se- 
cure cleanliness  of  person,  of  habitation  and  surroundings,  of  air, 
of  water,  and  of  soil.  Pollution  of  the  soil  should  be  especially 
guarded  against,  for  a  polluted  soil  means  impure  air  and  water,  and 
these  mean,  if  not  an  infectious  disease,  at  least  a  heightened  recep- 
tivity to  its  influence.  The  quality  of  the  drinking-water  used  must 
be  above  suspicion  of  contamination  by  the  poison.  Unless  the  latter 
can  be  positively  excluded,  all  drinking-water '  should  first  be  boiled. 
It  may  then  be  cooled  by  pure  ice. 

The  individual  predisposition  to  cholera  is  best  guarded  against 
by  keeping  the  body  clean  and  well  nourished,  and  the  mind  free  from 
worry.  Underfeeding,  anxiety,  overwork,  exposure  to  extremes  of 
temperature,   intemperance   in   eating   and   drinking   should    all   be 


ASIATIC  CHOLERA.  417 

avoided,  as  they  tend  to  reduce  the  resistance  of  the  system  to  the 
influence  of  the  morbid  poison. 

Certain  measures  of  personal  prophylaxis  which  have  proven 
useful  heretofore  should  be  adopted  wherever  cholera  prevails.  One 
of  the  best  of  these  is  the  use  of  sulphuric-acid  lemonade  as  a  drink. 
Ten  to  15  drops  of  dilute  sulphuric  acid  in  a  glass  of  water,  sweet- 
ened with  sugar,  may  be  drunk  instead  of  water.  Experience  with 
it  during  the  epidemic  of  1866  has  demonstrated  its  great  value  as 
a  preventive  of  cholera.  The  later  researches  of  Koch  have  also 
shown  that  the  "comma  bacillus,"  or  spirillum,  cannot  live  in  acid 
solutions.  Hence,  it  is  probable  that  if  the  contents  of  the  stomach 
were  always  kept  acid  no  infection  could  occur  through  absorption 
from  the  stomach. 

A  painless  diarrhea,  called  cholerine,  attacks  many  persons  dur- 
ing cholera  epidemics.  This  disorder  is  easily  curable  if  promptly 
attended  to,  but  if  allowed  to  run  on  it  may  develop  into  a  malig- 
nant attack  of  cholera. 

Among  the  means  of  securing  prompt  treatment  of  the  poorer 
classes  in  times  of  epidemics  is  the  establishment  of  numerous  public 
dispensaries,  where  medical  aid  can  always  be  obtained.  The  estab- 
lishment of  such  dispensaries  and,  if  possible,  of  temporary  hospitals 
in  the  crowded  portions  of  cities  is  a  very  important  part  of  the 
prophylactic  treatment. 

Inasmuch  as  it  seems  definitely  established  that  the  discharges 
from  the  stomach  and  intestines  are  the  active  agents  in  propagating 
the  disease,  the  immediate  disinfection  of  such  discharges  is  vitally 
important.  The  stools  and  vomited  matters  must  be  rendered  in- 
nocuous by  germicidal  agents,  such  as  mercuric;  chloride,  carbolic 
acid,  or  chloride  of  lime. 

Clothing  and  bedding  should  be  disinfected  with  superheated 
steam,  thorough  boiling,  or  fumigation  with  sulphur  dioxide  or 
chlorine.  Infected  articles  of  this  kind  should  not  be  sent  to  a 
laundry  until  they  have  been  thoroughly  disinfected  by  one  of  the 
above-mentioned  means. 

Apartments  which  have  been  occupied  by  cholera  patients  should 
be  thoroughly  disinfected  before  being  re-occupied,  and  afterward 
freely  exposed  to  the  air  by  opening  doors  and  windows.  The  walls 
may  also  be  washed  with  a  solution  of  mercuric  chloride. 

The  most  efficient  disinfectant  is  mercuric  chloride  in  the  pro- 
portion of  1  part  in  2000  of  the  material  to  be  disinfected.  The 
readiest  way  of  securing  disinfection  with  this  agent  is  to  add  a 

21 


418  TEXT-BOOK  OF  HYGIENE. 

solution  of  1  to  1000  to  an  equal  i^roportion  of  the  discharges  to  be 
rendered  innocuous.  The  mercuric  chloride  acts  slowly,  and  hence 
the  infected  material  should  be  exposed  to  the  action  of  the  disin- 
fecting agent  for  at  least  two  hours  before  it  can  safely  be  thrown 
into  sewers  or  cess-pools. 

There  are  several  serious  objections  to  the  indiscriminate  use  of 
mercuric  chloride  by  the  public  as  a  disinfectant.  In  the  first  place, 
it  is  intensely  poisonous,  and  its  perfectly  transparent  and  inodorous 
solution  might  be  readily  accidentally  drunk  and  cause  fatal  results. 
To  reduce  this  danger,  the  Committee  on  Disinfectants  of  the  Amer- 
ican Public  Health  Association  recommended  the  addition  of  perman- 
ganate of  potash  or  of  sulphate  of  copper  (blue  vitriol)  to  cobr  the 
solution.  Another  serious  objection  to  mercuric  chloride  is  that  it 
cannot  be  used  where  the  disinfected  material  must  pass  through  lead 
pipe,  as  this  is  rapidly  corroded  by  the  sublimate.  In  many  water- 
closets  it  cannot  therefore  be  used. 

Chloride  of  lime  (bleaching  powder)  has  been  found  to  be  a  very 
rapid  and  efficient  disinfectant,  as  well  as  a  deodorizer;  but  the 
chlorine,  upon  which  its  effectiveness  depends,  is  often  so  deficient  in 
proportion,  and  the  compound  so  readily  deteriorates  that,  unless  a 
preparation  can  be  obtained  that  contains  at  least  25  per  cent,  of 
available  chlorine,  it  may  prove  injurious  by  causing  a  false  sense  of 
security.  A  trustworthy  preparation  may  be  dissolved  in  water,  when 
required,  in  the  proportion  of  1  to  100.  An  objection  to  its  use  is  the 
pungent  odor  of  chlorine,  which  is  very  offensive  to  many  persons. 

Dr.  Koch  recommends  carbolic  acid,  which  he  has  sho^vn  will 
kill  the  "comma  bacilli"  in  a  dilution  of  1  to  20  of  water.  The  or- 
dinary preparations  of  carbolic  acid  sold  as  disinfectants  are,  how- 
ever, not  to  be  relied  on,  many  of  them  not  containing  more  than  2 
per  cent,  of  the  acid.  Further  dilution  of  these  agents  would  alto- 
gether destroy  their  disinfecting  power.  The  purer  article  is,  on  the 
other  hand,  too  expensive  to  be  used  as  a  disinfectant. 

Little's  soluble  phenyle  is  an  efficient  disinfectant  in  the  pro- 
portion of  2  per  cent.  (1  to  50).  It  is  furnished  of  uniform  strength, 
is  moderately  cheap,  non-poisonous,  and  readily  miscible  with  water. 
In  addition  to  its  disinfecting  power,  it  is  also  an  excellent  deodor- 
izer, promptly  removing  all  odors  of  decomposition  and  putrefaction. 
Its  only  objection  is  a  rather  pungent  although  not  unpleasant  odor, 
which  somewhat  resembles  creasote. 

In  the  very  beginning  of  an  epidemic,  prompt  isolation  of  the 
sick  and  thorough  disinfection   of  the  surroundings   of  the  patient 


RELAPSING   FEVER.  419 

may  check  the  spread  of  the  disease.  Much  cannot  be  expected  from 
these  measures,  however,  unless  the  local  sanitary  conditions  are  such 
as  offer  a  hindrance  to  the  development  of  the  cholera-poison.  It  is 
plain,  therefore,  that  prophylactic  measures  against  cholera,  to  be 
effective,  must  be  brought  into  requisition  before  the  epidemic  has 
begun.  After  the  outbreak  of  the  disease  it  may  be  too  late  to  put  the 
threatened  locality  in  a  good  sanitary  condition.  It  is  of  the  highest 
importance  that  preventive  measures  be  enforced  early.  Above  all, 
the  purity  of  the  drinking-water  must  be  safeguarded. 

RELAPSING   FEVER. 

Eelapsing  fever  was  first  clearly  described  by  Dr.  John  Eutty, 
in  his  "Chronological  History  of  the  Weather,  Seasons,  and  Diseases 
of  Dublin  from  1725  to  1765."^^     During  the  last  century  relapsing 


Fig.  44. — Spiroehseta  Obermeieri.     X  380. 

fever  was  frequently  met  with  in  epidemic  form  in  Ireland  and  Scot- 
land. In  1847  the  disease  invaded  a  number  of  the  larger  cities  of 
England.  From  1868  to  1873  it  prevailed  extensively  in  England 
and  Scotland.  On  the  continent  of  Europe  it  was  first  observed  in 
Kussia  in  1833.  In  Germany  it  was  not  recognized  as  a  distinct 
disease  until  1847,  but  did  not  prevail  epidemically  until  1868.  Since 
then  it  has  often  been  observed  in  that  country. 


'"London,  1770. 


420  TEXT-BOOK  OF  HYGIENE. 

Eelapsing  fever  is  very  prevalent  in  India,  where  it  was  first 
observed  in  1856  by  Sutherland.  In  China  and  in  the  countries  of 
Africa  bordering  on  the  Eed  Sea  the  disease  has  been  recognized  by 
observers. 

In  the  United  States  it  was  first  observed  among  emigrants  in 
Philadelphia  in  1844,  and  again  in  1869.  It  was  conveyed  to  other 
places,  but  has  never  prevailed  extensively  in  this  country.  It  has 
not  been  observed  in  the  United  States  since  1871. 

The  predisposing  causes  of  relapsing  fever  are,  above  all,  bad 
sanitary  surroundings.  Want  and  overcrowding  seem  to  be  much  less 
important  factors  than  in  typhus  fever. 

Although  relapsing  fever  has,  since  it  was  first  clear^.y  distin- 
guished from  typhus  and  other  continued  fevers,  been  recognized  as 
an  eminently  contagious  and  infectious  disease,  it  was  not  until  1873 
that  its  immediate  cause  became  known.  In  that  year  Obermeier  dis- 
covered in  the  blood  of  patients  ill  with  this  disease  a  minute,  spiral, 
mobile  organism,  now  known  as  the  spirillum  or  Spirochcete  Oher- 
meieri.     (Fig.  44.) 

Obermeier  and  other  observers,  prominent  among  Mdiom  is  Dr. 
Henry  V.  Carter,  have  demonstrated  the  constant  presence  of  these 
organisms  in  the  blood  during  the  attack.  Carter  and  Koch  have 
induced  the  disease  in  monkeys  by  inoculation  of  the  parasite,  and 
Moschutkowski  has  successfully  inoculated  it  in  the  human  subject. 
No  doubt  can  exist  at  the  present  day  that  the  spirillum  of  Obermeier 
is  the  true  cause  of  relapsing  fever. 

The  preventive  measures  consist  in  attention  to  details  of  per- 
sonal hygiene;  in  other  words,  local  sanitation,  disinfection  of  in- 
fected materials  (fomites),  and  complete  isolation  of  the  sick. 

TYPHOID  FEVER. 

The  first  accurate  clinical  accounts  of  typhoid  fever  date  from 
the  seventeenth  century,  when  Baglivi,  Willis,  Sydenham,  and  others 
described  cases  of  fever  which  in  their  clinical  characters  corres- 
pond to  the  disease  now  kno's\Ti  as  typhoid  fever.  Strother,  however, 
in  1729,  first  gave  a  description  of  the  anatomical  characters  of  the 
disease,  which  he  says  is  a  "symptomatical  fever,  arising  from  an 
inflammation,  or  an  ulcer,  fixed  on  some  of  the  bowels."  Bretonneau 
and  Louis,  in  France;  Hildenbrand,  in  Germany;  William  Jenner, 
in  England;  and  Drs.  Gerhard  and  Pennock,  in  this  country,  clearly 
pointed  out  the  essential  distinction  between  typhoid  and  other  fevers. 

At  the  present  day  typhoid  fever  is  met  with  everywhere  through- 


TYPHOID   FEVER. 


421 


out  the  world.  It  is  at  nearly  all  times  a  constituent  of  mortality 
tables.  It  affects  by  preference  persons  between  the  ages  of  15  and 
30  years,  although  no  age  is  entirely  exempt.  It  is  always  more 
prevalent  in  the  autumn  and  winter. 

The  disease  is  due  to  a  micro-organism  which  gains  entrance  into 
the  body  through  the  digestive  tract.  The  micro-organism  was  first 
observed  by  Eberth  and  Gaffky,  and  is  termed  bacillus  typhosus.  It 
is  found  in  the  intestinal  canal,  and  especially  in  the  characteristic 
intestinal  lesions  of  this  fever.  It  is  contained  in  the  dejections  of 
patients.  The  disease  is  not  immediately  contagious,  like  typhus 
fever. 


Fig.  45. — Pure  Culture  of  Typhoid  Bacilli,  showing  Clumping  when 

Brought  in  Contact  with  Blood  from  Typhoid  Patients. 

(Widal  reaction.) 

The  medium  through  which  the  poison  is  introduced  into  the 
body  may  be  drinking-water,  food,  milk,  or  other  articles  containing 
the  infective  agent.  Localized  epidemics  due  to  infected  water,  milk, 
and  oysters  have  been  frequently  reported.^** 

At  present  the  evidence  is  in  favor  of  the  view  that  cases  "of 
typhoid  fever  are  always  derived  from  pre-existing  cases.  The  germ 
may  exist  in  sewage  and  be  carried  from  place  to  place;  it  may  be 
carried  into  the  soil  from  cess-pools  receiving  typhoid  dejections,  and 
thus  gain  access  into  wells  and  pollute  the  drinking-water.  By.  the 
admixture  of  such  water  with  milk  or  other  food  the  disease  may 
be  propagated.     The  germs  are  frequently  carried  by  flies. 

The  prophylactic  measures  against  typhoid  fever  comprise  iso- 


'' See  ante,  pp.  Gl-04. 


422  TEXT-BOOK  OF  HYGIENE. 

lation  of  the  sick,  prompt  disinfection  of  the  discharges,  and  cleanli- 
ness in  the  widest  sense.  The  water-  and  food-  supplies  must  be 
carefully  guarded  against  contamination  with  the  bacillus,  excreta 
must  be  removed  from  the  immediate  vicinity  of  dwellings.  The 
requisites  for  prevention  may  be  summed  up  as  pure  air,  pure  v/ater, 
uncontaminated  food,  and  a  clean  soil. 

TYPHUS  FEVER. 

Wide-spread  pestilences  are  nearly  always  accompaniments  of 
famine  and  war.  Of  all  pestilential  diseases,  none  is  so  regular  in 
its  coincidence  with  these  conditions  as  typhus  fever.  The  earliest 
accounts  which  unquestionably  refer  to  this  disease  date  from  the 
eleventh  century,  when  it  was  observed  at  a  number  of  places  in  Italy. 
In  the  succeeding  centuries  isolated  accounts  of  it  appeared  in  the 
chronicles  of  the  times,  but  no  scientific  description  of  it  appeared 
until  the  sixteenth  century.  During  the  seventeenth,  eighteenth,  and 
the  early  part  of  the  nineteenth  centuries  it  prevailed  extensively 
throughout  Europe.  The  constant  wars  and  consequent  disturbances 
of  the  social  relations  of  the  people,  famines,  overcrowding,  filth, 
excesses  of  all  kinds,  contributed  largely  to  the  development  and 
spread  of  typhus  fever.  For  a  number  of  years  past  no  extensive 
epidemic  of  the  disease  has  been  observed,  although  in  this  country 
and  in  Europe  localized  outbreaks  are  frequently  met  with. 

Typhus  fever  is  somewhat  more  prevalent  in  the  winter  and 
early  spring  months  than  during  the  rest  of  the  year,  but  not  very 
markedly  so. 

At  present,  typhus  fever  is  nearly  always  limited  to  times  and 
places  where  the  conditions  favoring  its  development  exist.  Wherever 
overcrowding,  in  connection  with  filth,  insufficient  food,  and  bad 
habits  are  present,  tjq^hus  fever  is  likely  to  be  a  visitor.  Thus,  in 
overcrowded  and  ill- ventilated  emigrant  ships,  in  Jails  and  work- 
houses, and  in  camps,  especially  when  stress  of  weather  compels  the 
crowding  together  of  soldiers  in  close  huts  or  barracks,  the  disease 
frequently  breaks  out. 

When  typhus  appears  in  a  community,  those  classes  of  the 
people  who  are  subjected  to  the  conditions  just  mentioned  are  almost 
exclusively  attacked.  In  cities,  the  dwellers  in  crowded  tenements, 
or  in  courts  and  alleys,  suffer  most  severely — are,  in  fact,  almost  the 
only  ones  attacked.  An  exception  must,  however,  be  made  in  the  case 
of  hospital  physicians  and  attendants  where  typhus-fever  patients  are 
treated.     The  mortality  among  these  is  alwaj^s  large. 


YELLOW  FEVER.  423 

Typhus  fever  is  contagious  and  infectious.  The  cause  is  un- 
known. An  exposure  for  a  length  of  time  to  an  atmosphere  impreg- 
nated with  the  poison  may  suffice  to  induce  an  attack.  The  poison 
may  also  be  conveyed  from  place  to  place  in  fomites.  Physicians  may 
carry  it  in  their  clothing,  if  they  have  been  exposed  to  typhus  atmos- 
phere. 

The  prevention  of  typhus  fever  consists  in  the  institution  of  such 
measures  as  will  secure  pure  air,  pure  water,  a  clean  soil  and  dwell- 
ings, and  cleanliness  of  body  and  clothing.  When  an  outbreak  occurs, 
the  sick  should  be  promptly  isolated,  the  well  persons  removed  from 
the  building  in  v/hich  the  cases  have  occurred,  and  efficient  measures 
of  disinfection  carried  out.  The  sick  should  be  treated  in  the  open 
air  as  much  as  possible. 

YELLOW  FEVER. 

The  West  India  Islands,  the  Gulf  coast  of  Mexico,  the  northern 
part  of  the  Atlantic  coast  of  South  America,  and  a  limited  section  of 
the  west  coast  of  Africa  constitute  the,  present  home  of  yellow  fever. 
From  this  area  (the  so-called  "yellow-fever  zone")  the  disease  is  fre- 
quently transported  to  contiguous  or  distant  countries.  The  South 
Atlantic  and  Gulf  coasts  of  the  United  States  and  the  shores  of  the 
Caribbean  Sea  are  the  most  liable  to  the  epidemic  visitation  of  this 
pestilence. 

The  first  trustworthy  account  of  an  epidemic  of  yellow  fever 
dates  from  the  year  1635,  when  it  prevailed  on  the  Island  of  Guade- 
loupe. This  and  the  adjoining  islands  of  Dominica,  Martinique,  and 
Barbadoes  were  invaded  a  number  of  times  in  the  fifty  years  follow- 
ing the  above  date.  Jamaica  was  invaded  in  1655  and  Domingo  the 
year  after.  In  1693  the  first  appearance  of  the  disease  is  mentioned 
in  the  United  States,  being  observed  in  Boston,  Philadelphia,  and 
Charleston.  In  1699  it  appeared  as  an  epidemic  in  Vera  Cruz,  and 
re-appeared  in  Philadelphia  and  Charleston.  Since  the  year  1700,  the 
disease  has  appeared  in  an  epidemic  form,  at  one  or  more  places  within 
the  present  limits  of  the  United  States,  eighty  times,  the  last  con- 
siderable invasion  being  at  Jacksonville  and  other  places  in  Florida, 
and  Decatur,  in  Alabama,  in  1888,  and  to  a  lesser  extent  in  New 
Orleans  in  1903.  It  has  also  been  endemic  in  Cuba  until  recent 
years. 

In  South  America  yellow  fever  appeared  for  the  first  time  in 
1740.     In  1849  the  disease  was  imported  into  Brazil,  and  has  since 


424  TEXT-BOOK  OF  HYGIENE. 

then  been  endemic.  Peru  and  the  Argentine  Eepublic  have  also  suf- 
fered several  severe  visitations  of  3"ellow  fever   since   185-i. 

On  the  west  coast  of  Africa,  5^ellow  fever  seems  to  be  endemic 
in  the  peninsula  of  Sierra  Leone,  where  it  has  been  frequently  ob- 
served since  1816.  It  has  also  prevailed  epidemically  in  Senegambia 
and  a  number  of  the  islands  off  the  northern  portion  of  the  west 
African  coast.  In  Europe,  Spain  and  Portugal  have  been  the  only 
countries  to  suffer  from  yellow-fever  epidemics. 

Although  the  causes  of  yellow  fever  cannot  be  definitely  stated,  it 
is  well  known  that  it  only  occurs  endemically  within  the  tropics,  and 
prevails  epidemically  elsewhere  only  during  the  summer.  Of  180  epi- 
demics observed  in  the  United  States  and  Bermudas,  154  began  in 
July,  August,  and  September.  Of  the  remaining  26,  none  began  in 
the  six  months  from  November  to  April. 

A  temperature  of  26°  C.  and  a  high  humidity  are  generally  con- 
sidered essential  to  produce  an  outbreak  of  the  disease.  Of  other 
necessary  meteorological  conditions  nothing  is  known. 

That  the  specific  cause  of  yellow  fever  is  a  micro-organism  ap- 
pears probable  from  a  consideration  of  the  clinical  history  of  the 
disease  and  its  mode  of  propagation.  Up  to  the  present  time,  how- 
ever, none  of  the  various  organisms  described  as  causative  have  made 
good  the  claims  advanced  by  their  discoverers.  Surgeon-General 
Sternberg  has  shown  that  neither  the  organism  of  Freire,  of  Car- 
mona,  of  Babes,  of  F.  S.  Billings,  of  Finlay,  or  of  Gibier  is  the  true 
cause  of  yellow  fever. 

It  seems  to  be  Avell  established  that  the  most  filthy  and  insani- 
tary portions  of  cities  are  those  principally  ravaged  by  yellow  fever. 
It  has  also  been  firmly  established  that  the  disease  is  propagated 
through  the  agency  of  a  certain  species  of  mosquito  {stegomyia  fasci- 
ata),  the  latter  acting  as  an  intermediate  host. 

Yellow  fever  is  not  endemic  within  the  limits  of  the  United 
States,  and  has  probably  never  originated  here.  The  instances  in 
which  it  has  appeared  to  do  so  may  be  explained  by  the  persistence  of 
the  morbific  agent  through  one  or  more  winters,  or  by  a  new  importa- 
tion which  has  escaped  observation. 

Yellow  fever  frequently  breaks  out  on  shipboard  and  causes  much 
loss  of  life.  There  is  no  evidence  that  it  originates  on  ships;  it  is  only 
acquired  after  intercourse  with  an  infected  ship  or  infected  place. 

The  question  of  personal  contagion  of  yellow  fever  has  been 
decided  negatively.     The  disease  is  infectious,  but  persons  sick  with 


SCARLET  FEVER  AND  MEASLES.  425 

the  disease  do  not  communicate  it,  the  disease  being  communicated 
from  the  sick  to  the  well  by  the  bites  of  infected  mosquitoes. 

The  preventive  measures  indicated  against  yellow  fever  appear 
from  the  foregoing :  they  are  strict  sanitary  inspection  to  prevent  the 
introduction  of  a  person  sick  with  the  disease;  to  prevent  the  mos- 
quitoes from  coming  in  contact  with  yellow  fever  patients;  and  to 
employ  such  measures  as  would  lead  to  the  extermination  of 
mosquitoes. 

When  the  disease  becomes  epidemic  in  a  city,  the  inhabitants 
should  be  removed  to  temporary  camps  beyond  the  infected  area.  The 
experience  of  the  city  of  Memphis  in  1879,  and  that  of  various  locali- 
ties in  Florida  in  1888,  New  Orleans,  and  especially  Cuba,  encour- 
ages the  hope  that  by  prompt  isolation  of  the  sick  and  strict  enforce- 
ment of  sanitary  measures  with  especial  reference  to  mosquitoes,  the 
terrors  of  yellow  fever  can  be  largely  averted.  The  sick  should  be 
promptly  isolated,  and  protected  by  screening. 

SCARLET  FEVER  AND   MEASLES. 

The  early  history  of  these  two  contagious  eruptive  fevers  is  in- 
extricably blended  together.  Up  to  the  latter  half  of  the  seventeenth 
century  the  distinction  between  the  two  was  not  made  by  writers. 
Sydenham  was  among  the  first  who  clearly  separated  scarlet  fever 
from  measles  and  gave  it  a  distinct  name.  Since  the  Great  English 
Hippocrates,  the  essential  character  of  scarlet  fever  has  been  recog- 
nized by  all  physicians,  and  now  it  is  never,  or  but  rarely,  confounded 
with  measles. 

Of  the  two  diseases,  measles  is  somewhat  more  generally  preva- 
lent, although  both  occur  usually  in  epidemics.  There  is  hardly  a 
country  in  which  measles  has  not  been  observed,  while  the  continents 
of  Asia  and  Africa  have  remained  measurably  exempt  from  scarlet 
fever  up  to  the  present  time,  although  epidemics  have  been  recorded 
in  India  and  Japan. 

Hirsch  states  that  scarlet  fever  was  first  observed  in  this  country 
in  1735,  at  Kingston,  Mass.,  quoting  as  authorities  Dr.  Douglass,  of 
Boston,  and  Dr.  Golden,  of  New  York.  The  latter,  however,  in  a 
letter  to  Dr.  Fothergill,^"  clearly  describes  diphtheria,  and  not  scar- 
let fever.  Its  distribution  is  now  general,  but  it  is  said  to  be  much 
milder  in  the  southern  than  in  other  portions  of  the  United  States. 
The  prevalence  of  measles  is  not  limited  to  any  geographical  section. 

^Medical  Observations  and  Inquiries,  vol.  i,  p.  22L     London,  1776. 


426  TEXT-BOOK  OF  HYGIENE. 

Epidemics  of  measles  usually  begin  during  cold  weather.  Of 
530  epidemics  observed  in  Europe  and  North  America,  339  occurred 
during  the  colder  and  191  during  the  warmer  months.  In  313  of 
these,  the  height  of  the  epidemic  occurred  135  times  in  winter  and 
spring,  and  only  78  times  during  summer  and  autumn.  Scarlet  fever 
epidemics  occur  more  frequently  in  autumn  than  at  any  other  season. 

The  cause  of  scarlet  fever  or  of  measles  is  not  to  be  sought  in 
climatic  influences,  insanitary  surroundings,  or  special  natural  con- 
ditions of  air,  water,  or  soil.  Both  diseases  are  contagious  and  infec- 
tious, and  the  contagion  is  transmitted  either  by  fomites  (clothing, 
letters,  etc.),  infected  air,  drinking-water,  or  milk. 

Several  observers  have  claimed  the  discovery  of  the  specific  or- 
ganism of  scarlet  fever,  but  no  trustworthy  evidence  has  yet  been  fur- 
nished that  the  problem  is  solved.  On  a  previous  page  reference  has 
been  made  to  the  probable  connection  between  a  disease  of  milk-cattle 
and  scarlet  fever. 

The  measures  for  the  prevention  of  both  diseases  are  isolation 
and  thorough  disinfection. 

DIPHTHERIA. 

Under  the  names  of  Syriac  and  Egyptian  ulcers,  Aretseus,  a 
writer  of  the  second  century,  described  various  forms  of  malignant 
sore  throat.  The  disease  now  called  diphtheria  prevailed  at  various 
places  in  Europe  during  the  Middle  Ages.  In  this  country  it  was 
first  observed  about  the  middle  of  the  last  century,  and  in  1771  Dr. 
Samuel  Bard,  of  New  York,  described  it  very  accurately.  Although 
repeated  severe  outbreaks  occurred  in  Europe  in  the  early  part  of  the 
present  century,  it  was  not  until  1857  that  it  again  attracted  attention 
by  its  epidemic  prevalence  in  the  United  States.  Since  that  time 
it  has  spread  throughout  the  country,  and  is  at  present  one  of  the  most 
generally  diffused,  as  well  as  one  of  the  most  fatal,  of  the  contagious 
diseases.  In  certain  epidemics  its  malignancy  is  very  marked,  while 
in  others  it  seems  to  be  a  rather  mild  affection. 

Diphtheria  is  personally  contagious.  The  infecting  agent  is  a 
micro-organism  first  described  by  Loffler.  The  bacillus  can  be  dem- 
onstrated in  the  secretions  from  the  throat  or  nose  of  diphtheria 
patients.  The  diphtheria  bacillus  may  also  be  present  in  the  throats 
of  healthy  individuals  who  are  at  the  time  insusceptible  to  the  dis- 
ease, but  are  nevertheless  carriers  of  the  infection. 

The  question  as  to  the  identity  of  diphtheria  and  croup  is  not 


DIPHTHERIA.  427 

merely  a  clinical  one^  but  has  an  important  bearing  upon  preventive 
medicine.  If  croup  is  a  non-contagious  and  non-infectious  disease 
no  precautions  will  be  necessary  to  prevent  its  spread  to  healthy 
persons.  If,  on  the  other  hand,  diphtheria  and  croup  are  identical 
in  nature,  the  danger  of  infection  is  equally  great  in  both  diseases. 
With  the  evidence  furnished  by  the  bacteriologist  before  us,  we  can 
have  no  further  doubt  as  to  the  identity  of  the  two  diseases. 

Diphtheria  Is  inoculable  upon  animals,  and  may  through  this 
medium  be  transmitted  to  man. 

Persons  sick  with  diphtheria  should  be  carefully  isolated;  no 
one  but  the  immediate  attendants  should  be  allowed  to  come  in  con- 
tact with  the  patients.  Table  utensils,  bedding,  and  clothing  used  by 
the  sick  should  be  thoroughly  disinfected  by  steam  or  boiling  water 
before  being  used  by  others.    Intimate  contact  with  the  sick,  such  as 


Fig.  46.— Diphtheria  Bacilli.  (Park.) 

kissing,  should  be  strictly  prohibited.  There  seems  no  room  for 
doubt  that  the  diphtheria  bacillus  can  also  be  carried  in  the  clothing. 
Hence,  physicians  and  nurses  should  be  especially  careful  in  person- 
ally disinfecting  themselves  after  contact  with  a  case  of  diphtheria. 
After  death  or  recovery  of  the  patient,  the  apartment  occupied  during 
the  illness  should  be  disinfected. 

Children  recovering  from  diphtheria,  scarlet  fever,  measles,  or 
small-pox,  should  not  be  permitted  to  attend  school  for  at  least  four 
weeks  after  recovery.  It  is  believed  that  there  is  danger  of  infection 
ff)r  a  period  about  as  long  as  this,  and,  besides,  the  patients  are  apt 
to  be  weakened  from  the  effects  of  the  disease,  and  not  able  to  resist 
the  strain  of  continuous  mental  effort.  The  safest  plan  is  to  main- 
tain quarantine  until  two  successive  cultures  from  the  throat  show 
absence  of  diphllioria  bacilli. 


42S  TEXT-BOOK  OF  HYGIENE. 

DENGUE. 

The  disease  known  as  break-bone  fever,  dandy  fever,  and  by  vari- 
ous other  names,  was  first  discovered  in  the  United  States  in  1780, 
by  Dr.  Benjamin  Eush.  Dr.  Eush  describes  an  epidemic  wliich  pre- 
vailed duritig  the  summer  and  early  autumn  of  that  year  under  the 
name  of  'bilious  remittent  fever,"  but  the  symptoms  of  the  disease 
hardly  leave  any  doubt  that  it  was  dengue.  In  1779  and  1780  it  was 
also  observed  on  the  Coromandel  coast,  in  Egypt,  and  on  the  island 
of  Java.  In  1784  to  1788  dengue  also  prevailed  in  various  cities  of 
Spain.  In  1818  an  epidemic  appeared  in  Lima,  in  which  nearly  every 
one  of  the  70,000  inhabitants  was  attacked. 

In  1824-25  the  disease  again  prevailed  widely  in  India,  where 
it  was  known  as  the  "three-day  fever."  Isolated  outbreaks  occurred 
in  that  country  until  1853,  when  it  again  appeared  as  a  wide-spread 
epidemic,  and  in  1872  another  epidemic  outbreak  occurred  in  the  East, 
extending  from  Eastern  Africa  to  Arabia,  India,  and  China. 

In  1826  an  epidemic  of  dengue  appeared  in  Savanah,  and  in  the 
following  two  years  spread  over  the  southern  portion  of  the  United 
States  and  the  West  Indies,  reaching  the  northern  coast  of  South 
America.  In  1845  to  1849  the  disease  was  observed  in  Eio  Janeiro; 
in  1848  to  1850  in  the  South  Atlantic  and  Gulf  States.  In  1854  it 
was  observed  in  Southern  Alabama,  and  in  the  same  j^ear  in  the  West 
Indies.  In  1873  another  epidemic  appeared  in  the  lower  Mississippi 
Valley,  and  in  1880  an  outbreak  of  some  extent  occurred  in  New  Or- 
leans, Charleston,  and  other  places  on  the  Gulf  and  South  Atlantic 
coasts. 

Dengue  always  begins  in  the  summer  or  early  autumn,  and  ceases 
abruptly  with  the  advent  of  cold  weather.  It  is  almost  exclusively 
limited  to  hot  countries.  It  spreads  with  extreme  rapidity  wherever 
it  appears.  It  is  not  contagious;  the  manner  of  its  propagation  is 
not  known.  The  susceptibility  to  the  disease  appears  to  be  almost 
universal;  it  frequently  prostrates  the  majority  of  the  inhabitants 
where  an  outbreak  occurs.  During  the  epidemic  in  Calcutta  in  1871- 
72,  75  per  cent,  of  the  population  were  attacked.  In  the  United 
States  similar  epidemics  have  been  repeatedly  observed. 

Dengue  is  rarely  fatal.  It  seems  to  be  propagated  through  the 
atmosphere.     No  measures  of  prevention  are  known  or  available. 

EPIDEMIC  INFLUENZA. 

Accounts  of  epidemic  influenza  can  be  traced  back  to  the  year 
1173,  when  the  disease  was  observed  coincidently  in  Italy,  Germany, 


EPIDEMIC  INFLUENZA.  429 

and  England.  It  has  prevailed  epidemically,  at  varying  intervals,  to 
the  present  time.  In  the  fourteenth  century  3  epidemics  are  recorded ; 
in  the  fifteenth,  4;  in  the  sixteenth,  7;  in  the  seventeenth,  46.  Of 
these,  15  were  very  extensive,  some  of  them  prevailing  over  both  hemi- 
spheres contemporaneously. 

On  the  American  continent  influenza  was  first  recorded  in  1627, 
when  it  prevailed  in  New  England,  where  it  again  broke  out  in  1625. 
Following  this  there  is  no  notice  of  the  disease  in  America  until  1732, 
when  an  epidemic  began  in  the  New  England  States,  which  extended 
over  the  entire  globe.  Epidemics  occurred  during  the  remainder  of 
the  eighteenth  century  in  1737,  1757,  1761,  1767,  1772,  1781,  1789, 
and  1798.  During  the  present  century  the  disease  has  prevailed  more 
or  less  extensively  in  this  country  at  thirteen  different  times,  the  last 
epidemic  of  any  considerable  extent  being  in  1897. 

In  November,  1889,  an  epidemic  began  in  Eussia  which  rapidly 
spread  throughout  Northern  Europe,  reaching  the  United  States 
about  the  beginning  of  1890,  recurring  in  1891  and  1892.  The  epi- 
demic was  complicated  in  many  cases  by  pneumonia  of  a  fatal  char- 
acter. The  disease  manifested  itself  in  two  principal  forms,  the 
catarrhal  and  the  nervous.  Epidemics  more  or  less  severe,  in  char- 
acter have  occurred  since. 

A  curious  feature  of  epidemics  of  influenza  is  the  coincident  oc- 
currence of  outbreaks  of  a  somewhat  similar  affection  among  ani- 
mals, horses  and  dogs  being  especially  attacked. 

Influenza  is  an  acute,  specific,  infectious  disease,  not  directly  con- 
tagious. It  is  caused  by  a  very  minute  bacillus  first  observed  by 
Pfeiffer.  The  disease  frequently  appears  over  a  large  area  of  country 
almost  simultaneously.  Peculiarities  of  climate,  season,  meteorological 
conditions,  geological  formation,  or  racial  characteristics  have  no  ap- 
parent influence  upon  the  causation  or  spread  of  the  disease.  It  oc- 
curs more  frequently  in  the  winter  and  spring  than  during  the  summer 
or  autumnal  months.  The  investigation  into  the  epidemic  of  influ- 
enza among  horses,  referred  to  in  a  previous  chapter,^^  seems  to 
indicate,  however,  that  a  moist  and  impure  atmosphere  intensifles  the 
disease. 

No  measures  of  prophylaxis  can  be  indicated  except  avoidance  of 
anything  tending  to  depress  the  vital  powers,  as  well  as  disinfection 
of  the  upper  respiratory  passages  by  the  use  of  local  antiseptics. 


■''  Cliaptcr  I,  p.  29. 


430  TEXT-BOOK  OF  HYGIENE. 

EPIDEMIC  CEREBRO=SPINAL  MENINGITIS. 

This  disease  was  first  recognized  in  Geneva  in  1805.  In  the  fol- 
lowing year  it  was  noted  in  various  places  in  the  United  States.  Both 
in  Europe  and  in  this  country  localized  outbreaks  of  the  disease 
occurred  between  the  dates  above  mentioned  and  1816.  At  this  time 
the  disease  seemed  to  die  out  altogether,  but  in  1823  it  re-appeared  in 
various  parts  of  Europe  and  America. 

Cerebro-spinal  meningitis  appeared  in  1857  in  the  southwest  of 
France,  and  during  the  following  ten  years  spread  over  a  large  part  of 
the  country.  Algiers,  Italy,  Denmark,  and  Ireland  were  also  visited 
by  the  scourge.  In  1854  and  1861  Sweden  experienced  its  ravages, 
and  in  1859  Norway  was  invaded  by  the  disease,  which  continued 
for  nearly  a  decennium  in  the  latter  country.  From  1860  to  1867 
the  disease  prevailed  in  Holland,  Portugal,  Germany,  Ireland,  and 
Enssia.  , 

After  the  termination  of  what  may  be  called  the  first  epidemic, 
in  1816,  cerebro-spinal  meningitis  was  not  again  observed  in  this 
country  until  1842.  In  the  eight  years  succeeding,  it  prevailed  epi- 
demically throughout  almost  the  whole  United  States.  From  1861 
to  1873  it  was  noted  frequently  in  various  parts  of  the  country. 
Since  the  latter  year  the  reports  of  its  occurrence  in  this  country  have 
been  limited  to  sporadic  cases  or  localized  outbreaks. 

Cerebro-spinal  meningitis  is  an  acute  infectious  disease,  very 
fatal  in  its  tendency.  It  is  contagious.  The  disease  is  caused  by  a 
diplococcus  discovered  by  Weichselbaum  (Diplococcus  intraceUularis 
meningitidis).  Climate  has  no  influence  upon  its  origin,  but  season 
seems  to  stand  in  a  positive  relation  to  its  causation.  About  three- 
fourths  of  the  epidemics  noticed  have  occurred  during  the  winter  and 
spring  months.  The  disease  seems  to  show  no  preference  for  peculi- 
arities of  topographical  or  geographical  formation.  Overcrowding, 
overwork,  and  uncleanliness  have  an  important  influence  in  determin- 
ing an  outbreak.  It  is  especially  a  disease  of  youth  and  adolescence. 
Out  of  975  cases  occurring  in  New  York  only  150  were  over  20  years 
of  age,  while  of  the  remainder  665  were  under  10. 

The  prophylactic  measures  to  be  adopted  against  cerebro-spinal 
meningitis  consist  in  careful  attention  to  the  sanitary  conditions  of 
dwellings  and  streets,  avoidance  of  overwork  and  overcrowding  dur- 
ing times  of  epidemic,  isolation  of  the  sick,  and  disinfection  of  the 
sick-room  after  the  termination  of  the  disease. 


SYPHILIS.  431 


SYPHILIS. 


In  the  year  1494,  Charles  VIII  of  France,  in  command  of  a 
large  army,  invaded  Italy,  and  early  in  the  following  year  besieged 
Naples.  During  the  investment  of  the  city  a  very  severe  disease, 
characterized  by  ulcers  on  the  genitals,  violent  pains  in  the  head  and 
limbs,  and  generalized  cutaneous  eruptions  broke  out  among  the  be- 
siegers and  spread  rapidly  throughout  the  army  and  civil  population. 
On  the  return  of  the  army  to  France,  after  the  termination  of  the 
war,  the  disease  rapidly  spread  throughout  Europe,  and  the  literature 
of  the  early  part  of  the  sixteenth  century,  both  medical  and  lay,  teems 
with  references  to  it. 

From  the  locality  and  other  circumstances  connected  with  its 
epidemic  appearance  the  disease  acquired  various  names.  Thus,  the 
French  called  it  morbus  Neapolitmius,  or  mal  d'ltalie,  while  the 
Italians  termed  it  morbus  Gallicus,  or  mala  Franzos.  At  a  very  early 
period  it  was,  however,  clearly  recognized  that  the  disease  was  com- 
municated during  sexual  intercourse,  and  hence  it  was  usually  de- 
scribed in  medical  writings  under  the  name  lues  venerea,  while  in  the 
popular  literature  it  still  figured  as  the  Frenchman's  disease  {morbus 
Gallicus) .  The  name  syphilis  was  first  used  in  a  poem  descriptive  of 
the  disease,  written  in  1521  by  Fracastor,  a  physician  of  Verona. 

The  extraordinary  outbreak  of  the  disease  toward  the  end  of  the 
fifteenth  century  led  to  many  speculations  concerning  its  origin. 
As  it  attacked  persons  in  all  ranks  and  conditions  of  life,  "sparing 
neither  crown  nor  cross,"  in  the  words  of  a  contemporary  poet,  the 
favorite  explanation  was  that  meteorological  influences  had  much  to 
do  with  its  causation.  Many  ascribed  it  to  the  malign  influence  of 
the  stars.  The  Neapolitans  attributed  it  to  the  wickedness  of  their 
enemies,  the  French,  while  the  latter  laid  the  blame  on  the  filth  and 
immorality  of  the  Italians.  The  Spaniards  claimed  that  it  had  been 
imported  from  America  by  Columbus,  whose  first  expedition  re- 
turned to  Europe  in  1493.  There  are  records,  however,  which  prove 
that  the  disease  already  existed  in  Italy  in  the  latter  year.  In  other 
parts  of  Europe  the  Jews,  who  had  been  driven  out  of  Spain  by  the 
terrors  of  the  Inquisition,  were  accused  of  this,  as  of  many  other 
misfortunes  which  befell  the  people.  When  it  was  definitely  estab- 
lished that  the  disease  was  communicated  almost  solely  by  sexual 
intercourse,  the  theory  of  its  transatlantic  origin  became  very  popular. 
It  is  characteristic  of  human  nature  to  refer  the  origin  of  troubles 
resulting  from  its  own  vices  to  some  other  source,  if  possible.     This 


432  TEXT-BOOK  OF  HYGIENE. 

theory  of  the  American  origin  of  syphilis  is  still  held  by  some  writers. 
Within  a  few  years,  Dr.  Joseph  Jones,  of  New  Orleans,  claims  to 
have  found  evidences  of  syphilitic  disease  in  the  skulls  and  other 
bones  from  some  of  the  prehistoric  Indian  mounds  in  Mississippi. 
These  observations  of  Dr.  Jones,  have,  however,  not  been  verified 
by  others. 

Although  the  first  great  epidemic  of  syphilis  is  clearly  traceable 
to  the  period  between  the  years  1493  and  1496,  an  examination  of  the 
older  literature  reveals  many  descriptions  of  disease  which  can  only 
be  explained  by  assuming  them  to  refer  to  syphilis.  The  Old  Testa- 
ment Scriptures  contain  numerous  references  to  diseases  of  the  genital 
organs.  In  most  instances  these  troubles  are  ascribed  to  the  wrath  of 
God,  although  in  some  cases  a  pretty  shrewd  hint  is  given  as  to  the 
causation  of  the  affections.  Finaly-^  remarks  that  the  Hebrew  word 
translated  in  all  versions  of  the  Bible  by  "flesh"  signifies  also  the 
virile  member.  In  this  light,  the  references  in  Leviticus,  XIII-XV; 
Numbers,  XXV,  1-9,  XXXI,  16-18;  Deuteronomy,  IV,  3;  Joshua, 
XXII,  17;  I  Samuel,  V,  6,  9,  12;  Psalms  CVI,  28-30;  I  Corinth- 
ians, X,  8;  Ephesians,  II,  11;  and  Colossians,  II,  13,  receive  a  new 
interpretation.  Numerous  innuendoes  in  the  Latin  classics,  and  more 
or  less  exact  descriptions  in  the  medical  writings  of  Greece,  Eome, 
China,  and  India,  leave  no  room  for  doubt  that  venereal  diseases,  and 
probably  among  them  syphilis,  have  existed  from  the  earliest  times. 

At  the  present  day  syphilis  is  the  most  widely  prevalent  of  all 
contagious  diseases.  In  1873  Dr.  F.  E.  Sturgis  estimated  that  in 
New  York  1  person  out  of  every  18  suffered  from  it.  This  is  con- 
sidered a  moderate  estimate.  Dr.  J.  William  White,  of  Philadelphia, 
pronounces  the  opinion  that  "not  less  than  50,000  people  of  all 
classes  in  that  city  are  affected  with  syphilis."  On  this  basis  Gihon 
estimates  the  number  of  syphilitics  in  the  United  States  at  one  time 
at  2,000,000.23 

The  disease  is  transmitted,  in  the  vast  majority  of  cases,  during 
the  performance  of  the  sexual  act,  but  there  are  numerous  other  ways 
in  which  it  may  be  and  frequently  is  communicated.  In  the  special 
literature  of  the  subject  are  records  of  many  cases  in  which  the  dis- 
ease was  acquired  through  a  kiss,  a  bite,  the  act  of  suckling  (from 
infant  to  nurse,  and  conversely),  using  a  pipe,  glass-blowers'  mouth- 
piece, the  finger  of  a  midwife,  the  instrument  of  the  dentist  or  sur- 


'^'Arch.  f.  Dermat.  u.  Syphilis,  II  Jahrg.     1  Heft.,  p.  126. 

^The    Prevention    of    Venereal    Diseases    by    Legislation,     Sanitarian, 
June,  1882. 


GONORRHEA.  433 

geon,  inoculation  of  syphilitic  secretion  mixed  with  saliva  in  the 
process  of  tattooing,  and  many  other  ways.  Numerous  cases  have 
been  reported  where  physicians  were  inoculated  on  the  finger  while 
examining  a  syphilitic  patient.  Eecent  observations  seem  to  show 
that  the  disease  is  caused  by  a  spirillum — Spirocheta  pallida. 

The  prophylactic  measures  which  suggest  themselves  from  a  con- 
sideration of  the  nature  of  .the  disease  are  isolation  of  those  infected, 
regular  inspection  of  the  class  of  persons  through  whom  the  disease 
is  most  frequently  transmitted,  i.e.,  prostitutes,  and  individual  pre- 
cautions against  acquiring  it.  Greater  attention  to  cleanliness  of  the 
genital  organs  on  the  part  of  those  indulging  in  promiscuous  inter- 
course would  aid  largely  in  reducing  the  number  of  cases  of  syphilis. 

Eecent  investigations  by  Metchnikoff  show  that  syphilitic  infec- 
tion may  be  prevented  by  the  local  use  of  a  salve  containing  calomel, 
33  grams;  lanolin,  67  grams,  and  petrolatum,  10  grams.  The  appli- 
cation must  be  made  within  a  few  hours  after  coitus.  Hypodermic 
injection  of  a  solution  of  atoxyl  (an  arsenical  preparation),  in  doses 
of  75  centigrams,  followed  by  60  centigrams,  will  prevent  infection 
within  two  weeks. 


Fig.  47. — Micrococci  Gonorrhea  in  Pus.   (Park.) 

GONORRHEA. 

Gonorrhea  is  one  of  the  venereal  trio  which  is  responsible  for 
more  misery,  ill  health,  and  "race  suicide"  than  any  other  single 
sociologic  factor.  It  has  been  estimated  that  fully  80  per  cent,  of  cases 
of  pelvic  disease  in  women  is  caused  by  gonorrhea;  20  per  cent,  of 
blindness  is  due  to  gonorrheal  infection  of  the  new-bom;  50  per 
cent,  of  all  involuntary  chihlless  marriages  are  attributed  to  the 
same  cause.     Fitfh   asserts   that  of  every  one  hundred  women  who 

28 


434  TEXT-BOOK  OF  HYGIENE. 

have  married  men  formerly  infected  with  gonorrhea,  hardly  ten  re- 
main well.  The  disease  is  caused  by  a  diplococcus  {Micrococcus  gotir 
orrliece  or  gonococcus)  first  observed  by  Neisser,  in  1879. 

It  is  communicated  through  direct  contact  by  sexual  inter- 
course with  individuals  suffering  from  the  disease,  either  in  acute  or 
chronic  form.  The  chief  source  of  infection  is  prostitution,  and  in 
considering  prophylaxis  we  must  deal  with  one  of  the  most  intricate 
social  problems — the  so-called  "social  evil."  It  is  generally  conceded 
that  education  of  the  young  of  both  sexes  in  the  danger  lurking  in 
promiscuous  intercourse  and  a  general  dissemination  of  knowledge 
concerning  sexual  functions  and  venereal  diseases  will  go  far  to- 
ward remedying  the  evil.  It  is  claimed  that  an  injection  of  a  few 
drops  of  a  20  per  cent,  solution  of  protargol  post-coitum  will  prevent 
infection.  Blindness  can  be  prevented  by  attention  to  the  eyes  of 
the  new-born,  and  instillation  into  the  eyes  of  one  drop  of  a  solution 
of  silver  nitrate,  2  grains  to  the  ounce. 

The  third  member  of  the  venereal  group — the  soft  chancre,  or 
chancroid — is  a  localized  ulceration  caused  by  a  bacillus  discovered 
by  Ducrey,  in  1890.  The  affection  is  communicated  through  sexual 
intercourse,  and  seems  to  be  propagated  under  conditions  of  extreme 
uncleanliness. 

DISEASES  OF  ANIMALS  COMMUNICABLE  TO  MAN. 

Sheep-pock. — This  is  a  highly  contagious  and  infectious  disease 
of  sheep,  resembling,  in  its  symptoms,  course,  and  fatality,  small-pox 
as  it  occurs  in  the  human  race.  It  is  believed  by  Bollinger  to  be  dif- 
ferent from  the  form  of  small-pox  produced  in  sheep,  goats,  horses, 
and  other  animals  by  the  inoculation  of  human  small-pox.  Sheep- 
pock  can  be  inoculated  upon  other  animals  and  man,  but  only  pro- 
duces a  local  disease  at  the  point  of  inoculation  in  the  latter.  Sheep 
may  be  protected  against  this  disease  by  inoculation  with  sheep-pock 
virus  (ovination),  or  by  vaccination  with  vaccine  Ij^mph.  The  pecu- 
liarity of  sheep  vaccinia  is  that  it  is  a  more  or  less  generalized  disease, 
the  pustules  being  distributed  over  the  body.  Sheep-pock,  when  inoc- 
ulated upon  human  beings,  does  not  produce  a  generalized  infectious 
disease,  but  remains  entirely  local. 

Actinomycosis. — Veterinarians  have  frequently  observed  a  dis- 
ease attacking  the  jaws  of  cattle  and  producing  tumors,  often  with 
ulcerated  surfaces.  The  bone  is  usually  involved.  The  disease  has 
heretofore  been  generally  considered  a  sarcomatous  growth.  It  is  not 
seldom  observed  among  the  cattle  in  the  western  stockyards,  where 


ANIMAL  DISEASES  COMMUNICABLE  TO  MAN.  435 

it  is  known  in  the  vernacular  as  "swell-head."  Eecent  investigations 
by  Ponfick  have  shown  that  the  growth  consists  of  a  vegetable  para- 
site (actinoni3^ces),  and  that  it  is  inoculable  upon  other  animals,  and 
may  be  conveyed  to  man.  A  considerable  number  of  cases  have  been 
observed  in  human  beings  in  Germany,  where  the  disease  was  first 
described  by  Ponfick,  and  several  cases  have  been  reported  in  this 
country. 

Bovine  Tuberculosis  (Perlsucht). — In  cattle,  tuberculosis  occurs 
in  two  forms,  miliary  tubercles  and  cheesy  masses  in  the  lungs,  and 
firm,  pearly  nodules  on  the  serous  membranes.  These  nodules  do  not 
break  down,  but  may  become  calcified. 

Bovine  tuberculosis  is  a  frequent  disease  among  cows  kept  in 


Fig.  48. — Actinomyces  liominis    (Lung).     X   350. 

damp,  dark,  and  ill-ventilated  stables.  The  disease,  which  is  essen- 
tially the  same  as  human  tuberculosis,  tubercle  bacilli  being  present 
in  the  neoplasms,  is  believed  to  be  transmissible  to  human  beings 
by  means  of  the  milk  or  flesh  of  tuberculous  animals.  The  sale  of 
the  meat  of  tuberculous  cattle  should  be  prohibited. 

Rabies. — Hydrophobia  in  the  brute,  and  its  communicability  to 
man  through  a  bite,  has  been  known  from  the  remotest  antiquity.  It 
occurs  in  dogs,  foxes,  wolves,  horses,  and  other  animals,  and  may 
be  transmitted  from  any  of  them  to  human  beings. 

The  contagium  of  rabies,  the  infective  poison,  is  contained  prin- 
cipally in  the  saliva,  and  is  usually  inoculated  by  the  teeth  of  the 
mad  animal. 


436 


TEXT-BOOK  OF  HYGIENE. 


Pasteur  has  shown  that  the  greatest  virulence  of  the  rabies 
poison  resides  in  the  brain  and  spinal  cord  of  the  animal  suffering 
from  the  disease.  By  attenuation  of  this  virus,  the  nature  of  which 
has  not  yet  been  definitely  determined,  its  virulence  could  be  dimin- 
ished, and  by  inoculation  of  men  and  animals  with  the  attenuated 
virus  protection  against  the  disease  could  be  secured.  The  fact  seems 
likewise  established  that  the  period  of  incubation  of  the  inoculation- 
rabies  is  much  shorter  than  that  acquired  in  the  usual  way  by  bites  of 
rabid  animals.  Hence,  inoculation  with  the  attenuated  virus  protects 
the  bitten  individual  against  the  fatal  outbreak  of  the  unmodified 
disease. 


Fig.  49. — Colony  of  Anthrax  Bacilli^  slightly  Magnified. 
(After  Fliigge. ) 


Anthrax. — Anthrax,  or  splenic  fever  (milzbrand),  is  an  acute, 
highly  contagious  and  infectious  disease  of  herbiverous  animals, 
which  may  be  transmitted  by  inoculation  or  the  ingestion  of  the  virus 
to  other  animals  and  to  man. 

The  disease  is  due  to  a  minute  vegetable  organism  which  is  found 
in  the  blood  and  tissues  of  the  diseased  animals.  This  organism. 
Bacillus  antliracis,  was  first  discovered  by  Pollender,  and  has  been 
thoroughly  investigated  by  Davaine,  Pasteur,  Koch,  and  others. 

Inoculation  of  these  bacilli  or  their  spores  always  produces  the 
disease  in  susceptible  animals.  Skins  of  animals  not  infrequently 
contain  the  virus,  which  may  then  gain  access  to  the  blood  of  persons 
engaged  in  handling  them.     Knackers,  butchers,  wool-sorters,   and 


ANIMAL  DISEASES  COMMUNICABLE  TO  MAN.  437 

other  persons  liable  to  come  in  contact  with  sick  animals,  or  hand- 
ling their  flesh  or  hides,  are  subject  to  the  infection,  either  by  direct 
inoculation  (through  abrasions  of  the  skin,  etc.)  or  by  inhalation  of 
the  spores  of  the  bacillus.  An  intestinal  form  of  anthrax  in  man, 
mycosis  intestinalis,  is  sometimes  produced  by  the  consumption  of 
meat  of  animals  suffering,  when  killed,  of  splenic  fever.  Numerous 
instances  have  been  reported.  The  diagnosis  has  been  verified  by  dis- 
covering the  bacillus  of  anthrax  in  the  blood  and  various  organs  of 
the  individuals  attacked. 

In  view  of  the  dangerous  character  of  the  disease,  persons  coming 
in  contact  with  animals  suffering  from  anthrax  should  be  warned  of 
their  peril.     In  order  to  protect  other  animals  in  a  herd,  strict  isola- 


Fig.  50.— Bacillus  Mallei.   (Park.) 

tion  of  the  infected,  thorough  disinfection  of  the  stables  occupied 
by  them,  and  deep  interment  of  the  cadavers  of  those  dead  from  the 
disease  are  indicated.  The  vaccination  of  animals  with  cultures  of 
anthrax  bacilli  attenuated  by  being  grown  at  42°  C.  for  twenty-four  to 
forty-eight  hours  has  been  found  to  protect  animals  against  infection. 

Glanders. — Glanders,  or  farcy,  is  a  very  fatal  contagious  disease 
of  horses  which  may  be  communicated  to  other  animals  and  to  man. 
The  cause  of  glanders  has  been  discovered  by  Loffler  to  be  a  bacillus 
resembling  the  bacillus  tuberculosis.  Pure  cultures  of  this  bacillus, 
known  as  Bacillus  mallei,  were  inoculated  into  animals,  and  followed 
by  glanders  in  a  number  of  the  cases. 

The  infection  in  man  may  occur  either  upon  the  seat  of  excoria- 
tions of  the  skin  or  mucous  membranes,  especially  those  of  the  nose, 


438  TEXT-BOOK  OF  HYGIENE. 

conjunctiva,  and  possibly  by  inhalation  of  infective  particles  float- 
ing in  the  air. 

Animals  with  glanders  should  be  promptly  killed  and  their  cada- 
vers cremated  or  deeply  buried.  No  part  of  the  body  of  any  animal 
dead  with  glanders  should  be  allowed  to  be  used.  Infected  stables 
should  be  thoroughly  disinfected. 

RESUME  OF  SOME  OF  THE  INFECTIOUS  DISEASES. 

The  following  brief  summary  of  the  more  important  infectious 
diseases  will  be  found  useful : — 

Abscesses. — Localized  suppuration,  caused  principally  by  the  so- 
called  pyogenic  cocci  (staphylococci,  streptococci,  etc.),  but  may  be 
caused  by  other  bacteria  (B.  coli,  B.  typhosus).  So-called  "cold  ab- 
scesses" are  caused  by  the  tubercle  bacillus.  The  affection  may  be 
prevented  by  thorough  sterilization  of  instruments  and  dressings 
which  come  in  contact  with  a  wound,  as  well  as  by  rendering  such 
wound  free  from  germs.  Laboratory  diagnosis:  Demonstration  of 
germ  in  the  pus. 

Actinomycosis. — Caused  by  a  fungus,  actinomyces  hovis  or  ray 
fungus.  It  is  a  disease  of  animals  communicated  to  man  by  way  of 
the  alimentary  or  respiratory  tract  or  wounds.  Prophylaxis  includes 
the  destruction  of  the  abscesses.  Laboratory  diagnosis:  Demonstra- 
tion of  characteristic  fungus  in  the  discharges. 

Anthrax. — Caused  by  Bacillus  anthracis.  It  is  a  disease  of  ani- 
mals communicated  to  man,  and  may  be  transmitted  by  direct  contact 
or  by  insects,  the  consumption  of  flesh  from  the  diseased  animal 
(intestinal  anthrax),  or  inhaling  the  dust  from  the  hair  of  the  in- 
fected animals  (pulmonary  anthrax,  or  wool-sorters'  disease).  The 
prophylaxis  includes  isolation  of  the  diseased  animals,  the  complete 
destruction  of  the  carcasses,  and  vaccination  of  the  exposed  stock. 
Laboratory  diagnosis:  Demonstration  of  characteristic  bacillus  in  the 
blood  or  point  of  infection. 

Cholera. — Caused  by  Spirillum  cholerce.  Transmitted  by  water 
and  food,  principally  the  former.  The  period  of  quarantine,  one 
week.  Prophylaxis  consists  in  sterilizing  the  food  and  drink,  and 
disinfection  of  the  stools.  Laboratory  diagnosis:  Cultivation  of  the 
spirillum  from  the  feces. 

Diphtheria. — Caused  by  Bacillus  dipMherice  of  Klebs-Loffler. 
Transmitted  by  direct  contact,  fomites,  and  air.  Period  of  quarantine, 
until  two  successive  cultures  from  the  throat  are  negative.     Prophyl- 


RESUME  OF  SOME  INFECTIOUS  DISEASES.  439 

axis  consists  in  isolation,  disinfection  of  upper  respiratory  passages 
by  mild  antiseptics,  immunization  with  antitoxin,  disinfection  of 
premises.  Laboratory  diagnosis:  Cultivation  of  the  Klebs-Loffler 
bacillus  on  blood  serum,  from  the  throat  of  suspected  patients. 

Dysentery. — The  bacillary  form  is  caused  by  Bacillus  shigce,  the 
amebic  form  by  Anieba  dysenterice.  Transmitted  by  water  and  food. 
Prophylaxis  consists  in  disinfection  of  the  stools  and  sterilization  of 
food  and  drink.  Laboratory  diagnosis:  The  cultivation  of  the  bacil- 
lus from  the  feces  or  the  microscopic  demonstration  of  the  ameba. 

Glanders. — Caused  by  Bacillus  mallei.  Transmitted  by  inhala- 
tion of,  or  infection  of  wounds  with  nasal  secretions  and  discharges 
from  infected  animals.  Prophylaxis  consists  in  disinfection  of  se- 
cretion and  destruction  of  carcasses.  Laboratory  diagnosis:  Injection 
of  culture  from  secretion  into  guinea-pigs ;  development  of  swelling  of 
testicle  is  characteristic;   to  detect  latent  glanders,  use  mallein. 

Gronorrhea.  —  Caused  by  Micrococcus  gonorrliece  (gonococcus). 
Transmitted  by  sexual  contact,  rarely  fomites.  Prophylaxis  consists 
in  strict  avoidance  of  promiscuous  intercourse  and  local  disinfection 
after  such  intercourse.  Laboratory  diagnosis:  Demonstration  of  the 
gonococci  in  the  discharge,  or  cultivation  on  serum-agar. 

Hydrophobia.  —  Caused  by  unknown  micro-organism.  Trans- 
mitted by  bites  of  rabid  animals.  Prophylaxis  consists  in  the  destruc- 
tion of  animals  suffering  from  rabies  and  isolation  of  those  bitten; 
cauterization  of  wound  and  Pasteur  treatment.  Laboratory  diagnosis: 
Eeproduction  of  the  disease  by  subdural  inoculation  into  the  lower 
animals ;  demonstration  of  certain  histological  changes  in  the  ganglia 
of  suspected  animals. 

Influenza. — Caused  by  Bacillus  influenza  of  Canon  and  Pfeiffer. 
Transmitted  by  fomites  and  inhalation.  Prophylaxis  consists  in  iso- 
lation and  disinfection  of  discharges.  Laboratory  diagnosis:  Demon- 
stration of  bacillus  in  the  secretions  from  respiratory  passages. 

Leprosy. — Caused  by  the  Bacillus  leprce.  Believed  to  be  trans- 
mitted by  insects.  Prophylaxis  consists  in  isolation  and  destruction 
of  insects  and  vermin.  Laboratory  diagnosis:  Demonstration  of  the 
bacillus  in  the  affected  tissues. 

Malaria. — Caused  by  the  Plasmodium  malarice.  Transmitted  by 
mosquitoes  (anopheles).  Prophylaxis  consists  in  destruction  of  mos- 
quitoes and  prophylactic  use  of  quinine.  Laboratory  diagnosis: 
Demonstration  of  the  parasite  in  the  blood,  either  fresh  or  stained, 
of  the  patient. 

Measles. — Supposed   to  be   caused  by  a  bacillus   discovered  by 


440  TEXT-BOOK  OF  HYGIENE. 

Canon  and  Pielicke.  Transmitted  by  direct  contact  and  fomites. 
Period  of  quarantine,  sixteen  days.  Prophylaxis  consists  in  isola- 
tion, disinfection  of  fomites,  skin,  and  secretions  from  nose  and 
mouth,  and  final  fumigation  of  sick-room. 

Mumps. — Cause  unknown.  Transmitted  by  direct  contact. 
Period  of  quarantine,  twenty-four  days.  Prophylaxis  consists  in  iso- 
lation and  disinfection  of  secretions  from  upper  respiratory  passages. 

Plague. — Caused  by  Bacillus  pestis.  Transmitted  by  rats,  fleas, 
and  inhalation  of  patient's  sjiutum.  Period  of  quarantine,  ten  days. 
Prophylaxis  consists  in  isolation,  destruction  of  rats  and  vermin,  and 
disinfection  of  all  discharges.  Laboratory  diagnosis:  Demonstration 
of  the  bacillus  in  the  pus  from  the  buboes;   animal  inoculation. 

Pneumonia. — Caused  by  Diplococcus  lanceolatus  (pneumococcus). 
Transmitted  by  fomites.  Prophylaxis  consists  in  isolation  and  disin- 
fection of  sputum.  Laboratory  diagnosis:  Demonstration  of  the 
pneumococci  in  the  sputum. 

Relapsing  Fever. — Caused  by  Spirillum  obermeieri.  Mode  of 
transmission  obscure;  possibly  insects.  Prophylaxis  consists  in  the 
protection  from  bites  of  insects.  Laboratory  diagnosis:  Demonstra- 
tion of  the  spirillum  in  the  blood. 

Scarlet  Fever. — Cause  unknown.  Transmitted  by  direct  contact, 
fomites,  milk.  Period  of  quarantine,  ten  days  after  exposure;  period 
of  isolation  of  patient,  about  six  weeks.  Prophylaxis  consists  in  isola- 
tion, disinfection  of  skin  and  fomites,  and  final  fumigation  of  sick- 
room. 

Small-pox. — Cause  unknown.  Transmitted  by  direct  contact  and 
fomites.  Period  of  quarantine,  16  days  after  exposure;  period  of 
isolation  of  patient,  until  disappearance  of  eruption.  Prophylaxis 
consists  in  isolation,  vaccination,  disinfection  of  skin  and  fomites, 
and  final  fumigation. 

Syphilis. — Supposed  to  be  caused  by  Spiroclieta  pallida.  Trans- 
mitted by  direct  contact  (coitus,  kissing)  and  fomites.  Prophylaxis 
consists  in  disinfecting  the  mouth  of  patient  and  exclusive  use  of 
eating  and  drinking  utensils.  The  patient  should  be  enjoined  from 
kissing  and  such  contact  with  the  well  as  would  be  liable  to  lead  to 
infection.  Physicians  and  dentists  should  be  particularly  careful  not 
to  infect  themselves,  and  more  especially  not  to  become  carriers  of 
infection.  Laboratory  diagnosis:  Demonstration  of  the  spirochete  in 
the  lesions. 

Tetanus. — Caused  by  Bacillus  tetani.  Transmitted  by  infecting 
deep  wounds  with  earth  containing  the  micro-organism.     Prophylaxis 


RESUME  OF  SOME  INFECTIOUS  DISEASES.  441 

consists  in  free  incision,  cauterization,  and  injection  of  antitetanic 
serum.  Laboratory  diagnosis:  Demonstration  of  the  bacillus  on  the 
objects  which  caused  the  injury,  by  the  aid  of  animal  inoculations. 

Typhoid  Fever. — Caused  by  the  Bacillus  typhosus.  Transmitted 
through  water,  milk,  food,  and  fomites,  also  by  contact  with  infected 
feces.  Prophylaxis  consists  in  disinfection  of  stools  and  urine  of 
patient  as  well  as  fomites;  purification  of  polluted  water-supply; 
sterilization  of  suspected  food  and  drink;  protection  against  flies. 
Laboratory  diagnosis:  Demonstration  of  the  typhoid  bacillus  in  the 
blood ;  Widal  test ;  test  of  urine  for  diazo-reaction. 

Typhus. — Cause  unknown.  Transmitted  by  direct  contact,  fo- 
mites, and  air.  Period  of  quarantine,  fourteen  days;  period  of  isola- 
tion, about  four  weeks.  Prophylaxis  consists  in  isolation  and  final 
fumigation. 

Tuberculosis. — Caused  by  Bacillus  tuberculosis.  Transmitted  by 
inhalation  of  dried  sputum,  consumption  of  infected  food.  Prophy- 
laxis consists  in  disinfection  of  sputum  and  protection  of  food-supply. 
Final  fumigation  of  premises.  Laboratory  diagnosis:  Demonstration 
of  the  tubercle  bacillus  in  the  sputum  or  other  discharges;  the  tuber- 
culin test. 

Whooping  Cough. — Cause  unknown.  Transmitted  by  direct  con- 
tact and  by  inhalation  of  ejected  secretions.  Prophylaxis  consists  in 
isolation,  disinfection  of  sputum,  and  final  fumigation  of  premises. 

Yellow  Fever. — Cause  unknown.  Transmitted  by  bite  of  mos- 
quito (stegomyia  fasciata).  Period  of  quarantine,  fourteen  days  after 
exposure.    Prophylaxis  consists  in  protection  against  mosquitoes. 


QUESTIONS  TO  CHAPTER  XVII. 

HISTORY  OF  EPIDEMIC  DISEASES. 

Of  what  advantage  is  the  study  of  the  history  of  epidemic  diseases  ? 
What  are  some  of  the  most  important  maladies  of  this  class?  To  what  are 
they  all  due? 

What  are  some  of  the  synonyms  of  the  Oriental  plague?  What  are 
some  of  its  characteristic  symptoms?  What  is  the  date  of  the  first  clear 
account  of  it?  How  long  did  this  epidemic  persist?  When  did  it  make  its 
second  incursion  into  Europe?  What  Avas  one  of  the  peculiar  symptoms  of 
this  epidemic?  What  was  its  estimated  mortality?  What  were  some  of  its 
moral  effects  ?  When  was  its  final  incursion  into  Western  Europe  ?  What 
minor  epidemics  of  it  have  there  been  since?  When  was  the  last,  and  where? 
Is  it  now  endemic  anywhere?  To  what  was  its  origin  formerly  ascribed? 
What  conditions  are  always  present  when  the  plague  prevails?  What  is 
another  evident  factor  in  its  causation?  How  is  it  generally  transmitted?  Is 
it  a  germ  disease?    What  are  the  measures  of  prevention  therefore  indicated? 

What  is  the  sweating  sickness?  What  are  some  of  its  characteristic 
symptoms  and  peculiarities?  What  is  evidently  its  nature?  Is  there  any 
class  exempt  from  it?  What  favors  its  spread?  What  relation  has  it  to 
cholera?  When  did  it  first  appear  in  England?  When  for  the  last  time? 
Where  has  it  appeared  since?     Have  there  been  many  outbreaks  in  Europe? 

What  are  the  earliest  details  regarding  small-pox?  ^Vhen  was  it  sup- 
posed to  have  been  introduced  into  Europe?  Who  made  the  first  distinct 
reference  to  it  in  medical  literature?  When?  What  was  the  estimated  mor- 
tality from  this  disease  in  Europe  previous  to  the  introduction  of  vaccination? 
Where  has  it  been  very  fatal  in  its  devastations  in  recent  years?  What  other 
countries  and  peoples  have  suffered  from  it?  What  is  the  mortality  from 
unmodified  small-pox?  How  is  the  disease  transmitted?  What  factors  are 
necessary  to  cavise  an  outbreak?  Wliat  may  carry  the  poison?  For  what 
distance  about  a  patient  may  the  air  be  infectious?  In  what  stages  of  the 
disease  is  it  contagious?  What  races  are  more  commonly  attacked,  and  among 
which  is  it  more  fatal? 

Does  one  attack  of  small-pox  always  confer  future  immunity  from  the 
disease?  Wherein  is  the  popular  belief,  that  persons  suffering  from  an  acute 
or  chronic  disease  are  less  liable  to  incur  small-pox  than  the  healthy,  at 
fault?  Which  maladies  are  most  likely  to  afford  this  immunity?  When  does 
such  immunity  appear  to  cease? 

When  do  epidemics  of  small-pox  usually  begin?  In  what  seasons  do  they 
spread  most  rapidly?  Does  the  disease  spread  rapidly  at  first?  Has  the 
specific  organism  of  small-pox  been  certainly  discovered? 

When  was  the  first  attempt  to  limit  the  fatality  of  small-pox  by  inocu- 
lation made  in  Europe?     When  was  the  practice  introduced  into  England,  and 

(442) 


QUESTIONS  TO  CHAPTER  XVII.  443 

by  whom?  What  were  the  details  of  the  method  as  then  practiced?  What 
were  the  characteristics  of  the  disease  thus  produced?  Was  the  practice 
altogether  without  danger  to  the  one  inoculated?  What  other  grave  objec- 
tion was  there  to  such  inoculations?  When  was  the  practice  of  inoculation 
introduced  into  America,  and  by  whom?  How  long  was  it  continued  in 
England  and  in  America?  Wliere  was  it  practiced  before  its  introduction 
into   Europe  ? 

What  led  to  the  discovery  of  vaccination?  Who  first  practiced  it? 
When?  To  whom  is  due  the  merit  of  demonstrating  and  publishing  the  value 
of  vaccination?  When  did  he  perform  his  first  vaccination,  and  with  what 
results?  When  did  he  publish  the  first  pamphlet  in  relation  to  it?  When 
was  vaccination  introduced  into  America,  and  by  whom? 

What  is  the  relation  of  vaccinia  (cow-pox)  to  small-pox?  What  are 
the  symptoms  produced  in  the  case  of  a  successful  vaccination?  When  may 
the  individual  be  considered  to  be  thoroughly  protected?  Is  the  immunity 
absolute  for  life?  ^Vliat  is  the  character  of  an  attack  of  small-pox  in  an 
individual  who  has  once  been  vaccinated?  Does  repeated  vaccination  increase 
the  immunity?  What  effect  has  vaccination  had  on  the  mortality  from  small- 
pox?    On  the  prevalence  of  the  disease? 

What  important  precaution  should  be  observed  in  all  vaccinations  ? 
Why?  When  should  children  be  vaccinated?  When  should  they  be  revac- 
cinated?  What  are  some  of  the  peculiarities  following  upon  revaccination  ? 
What  are  some  of  the  objections  urged  against  humanized  virus?  Are  these 
all  valid?  'VlTiat  are  some  of  its  advantages?  How  is  it  to  be  inoculated? 
How  is  animal  virus  obtained?  How  is  it  to  be  used?  In  what  way  do  the 
results  from  using  it  differ  from  those  of  humanized  virus? 

What  complications  are  likely  to  occur  in  the  course  of  the  vaccinia? 
What  are  some  of  the  causes  of  these  complications?  What  subjects  are 
unfavorable  ones  for  vaccination?  When  may  vaccination  be  properly  de- 
layed? What  diseases  may  be  communicated  by  or  may  follow  vaccination? 
What  cases  should  be  promptly  revaccinated  ? 

What  besides  vaccination  is  highly  important  in  the  prophylaxis  of 
small-pox?  What  precautions  should  be  observed  in  the  care  of  one  sick 
with  small-pox?  What  are  the  best  disinfectants  for  such  cases?  When 
is   all   danger   of   infection  over? 

Where  is  Asiatic  cholera  endemic?  What  can  be  said  of  its  ravages 
there?  When  were  the  first  authentic  accounts  of  it  given?  When  did  the 
disease  first  become  epidemic  outside  of  India?  What  were  some  of  the 
countries  visited?  W^hen  did  it  first  appear  in  England?  When  and  where 
in  America?  When  did  this  outbreak  from  India  end?  When  did  it  again 
become  pandemic,  and  how  long  before  it  again  reached  the  United  States? 
What  were  the  ports  through  which  it  entered?  How  long  did  it  persist  in 
this  country?  How  long  in  South  America?  When  was  the  next  visitation 
to  this  country?  What  parts  of  South  America  were  first  invaded  at  this 
time?  Where  else  was  cholera  raging  during  these  periods,  and  where  was 
it  practically  endemic? 


444  TEXT-BOOK  OF  HYGIENE. 

When  was  the  last  serious  impoi-tation  of  the  disease  into  this  country, 
and  by  what  port  did  it  enter?  Where  else,  and  when,  have  there  been  im- 
portant epidemics  since  this  date?  What  does  the  history  of  all  these  epi- 
demics demonstrate?  What  factors  must  concur  that  there  may  be  an 
epidemic  ?  What  is  the  specific  cause  of  cholera  ?  Who  discovered  it  ?  When  ? 
Is  the  disease  contagious?  How  is  it  spread?  What  conditions  seem  to  be 
necessary  for  its  propagation?  When  do  outbreaks  usually  occur,  and  when 
do  they  subside?  Why  is  the  disease  endemic  in  India?  How  do  these  con- 
ditions predispose  the  victims  to  the  disease?  Are  these  conditions  peculiar 
to  India?     Where  else  may  they  exist? 

How  is  the  specific  organism  given  off  from  the  human  body?  How 
does  it  usually  gain  entrance  into  others?  What  evidence  is  there  of  this 
(see  chapter  on  Water)  ?  What  other  agencies  may  aid  in  disseminating 
the  disease? 

What  are  the  measures  of  prophylaxis  against  cholera?  How  can  the 
entrance  of  the  disease  into  a  community  be  prevented?  What  measures  of 
local  sanitation  may  be  even  more  eff"ective?  Why?  How  shall  the  drinking- 
water  and  food  be  rendered  harmless? 

How  may  one  guard  against  an  individual  predisposition  to  cholera? 
What  measure  of  personal  prophylaxis  is  useful  ?  What  is  the  rationale  of 
this?  What  disease  may  simulate  cholera  during  an  epidemic,  and  to  what 
is  it  often  due? 

In  times  of  cholera  epidemics,  what  sanitary  measures  are  to  be  estab- 
lished? What  disinfectants  are  to  be  used?  What  articles  are  to  be  disin- 
fected, and  how?  What  are  some  of  the  objections  to  the  indiscriminate  use 
of  the  bichloride  of  mercury?  What  may  be  used  in  its  stead?  What  does 
Koch  recommend,  and  what  objection  is  there  to  its  use?  What  plan  should 
be  pursued  at  the  beginning  of  an  epidemic? 

When  was  relapsing  fever  first  described?  \\Tien  was  it  first  observed 
in  America?  When  did  it  last  appear  here?  What  predisposing  conditions 
favor  it?  ^Vhat  is  its  specific  exciting  cause?  Where  is  the  germ  found? 
What  are  the  preventive  measures  to  be  used  against  relapsing  fever? 

How  long  has  typhoid  fever  been  known  as  a  distinct  disease?  Where 
is  typhoid  fever  common?  When  is  it  most  prevalent?  What  persons  and 
ages  are  most  subject  to  it?  To  what  is  the  disease  due?  Where  is  it  found? 
Is  the  disease  contagious?  Where  is  the  poison  developed?  Does  it  arise 
de  novo?  How  may  the  poison  be  conveyed  to  human  beings?  What  prophyl- 
axis may  be  employed  against  typhoid  fever  ?  What  are  the  requisites  for 
prevention  ? 

When  were  the  earliest  authentic  accounts  of  typhus  fever  made?  What 
predisposing  conditions  favor  its  development  and  spread  ?  When  is  it  more 
prevalent?  By  what  is  it  limited?  Where  is  it  apt  to  occur?  What  class 
of  persons  is  most  likely  to  be  attacked?  Is  it  contagious?  How  may  it  be 
prevented?  What  measures  are  to  be  pursued  during  an  outbreak  of  the 
disease? 


QUESTIONS  TO  CHAPTER  XVII.  445 

Where  is  the  present  home  of  yellow  fever?  What  localities  are  most 
liable  to  epidemics  of  this  disease?  What  is  the  date  of  the  first  authentic 
account  of  it  ?  When  and  where  did  it  first  appear  in  the  United  States  ? 
Has  it  ever  originated  here  or  been  endemic?  How  many  times  has  it  been 
epidemic  in  this  country  in  the  last  two  centuries?  When  and  where  was 
the  last  epidemic?  In  what  season  do  epidemics  occur?  In  what  climates  may 
it  be  endemic?  What  climatic  conditions  seem  to  be  necessary  for  an  out- 
break? What  is  probably  its  specific  cause?  Has  this  been  discovered?  What 
is  one  of  the  principal  factors  in  its  spread?  Is  the  disease  contagious? 
How  is  the  poison  conveyed?  What  is  necessary  to  the  propagation  of  the 
disease?     What  preventive  measures  are  to  be  employed  against  yellow  fever? 

What  is  to  be  done,  should  the  disease  become  epidemic  in  a  city?  Will 
this  be  efficacious  in  most  cases? 

Who  first  distinguished  between  scarlet  fever  and  measles?  Which  dis- 
ease is  more  prevalent?  What  countries  have  been  practically  exempt  from 
scarlet  fever  ?  When  was  scarlet  fever  first  observed  in  America  ?  When  do 
epidemics  of  measles  usually  begin?  When  of  scarlet  fever?  What  is  the 
exciting  cause  of  each  disease,  and  how  may  it  be  conveyed?  Have  bad  hy- 
gienic surroundings  an  influence  in  the  propagation  of  either  disease?  What 
are  measures  for  prevention  in  both  cases? 

How  old  is  the  history  of  diphtheria  ?  When  was  it  first  observed  in 
this  country?  When  did  it  again  prevail  epidemically  here?  How  are  vari- 
ous epidemics  marked?  Is  it  contagious?  How  may  it  be  conveyed?  What 
is  the  exciting  cause?  Is  diphtheria  identical  with  croup?  What  plan  should 
be  pursued  for  prevention  regarding  the  two  diseases?  Is  diphtheria  trans- 
missible to  animals?  What  precautions  should  be  taken  with  a  person  sick 
with  diphtheria?  How  long  should  children  who  have  had  diphtheria,  scarlet 
fever,  small-pox,  or  measles  be  detained  from  school?     Why? 

What  is  dengue?  When  and  by  whom  was  it  first  observed  in  the 
United  States  ?  When  does  an  epidemic  begin,  and  when  does  it  stop  ?  To 
what  countries  is  the  disease  limited?  Is  it  contagious?  How  is  it  propa- 
gated? Who  are  susceptible?  What  are  the  measures  of  prevention  that  may 
be  employed?     Is  the  disease  fatal? 

What  is  the  date  of  the  earliest  accounts  of  epidemic  influenza?  What 
are  some  of  its  synonyms  ?  When  did  it  first  prevail  in  America  ?  When  was 
the  last  epidemic?  How  was  this  one  complicated?  Are  animals  subject  to 
this  disease?  Is  it  contagious?  How  is  it  transmitted?  When  is  it  most 
prevalent?     What  are  the  measures  of  prophylaxis  against  it? 

When  was  epidemic  cerebro-spinal  meningitis  first  recognized?  When 
did  it  appear  in  America?  When  was  the  first  epidemic  here?  When  the 
next?  When  the  last?  Is  it  contagious  or  infectious?  What  is  its  tendency? 
When  is  it  most  liable  to  occur?  What  influence  has  climate  upon  it?  What 
factors  seem  to  favor  an  outbreak?  What  ages  are  most  subject  to  it?  What 
is  the  prophylactic  treatment? 

When  and  where  does  syphilis  seem  to  have  had  its  origin?  Are  there 
any  traces  of  evidence  of  its  existence  before  this?     What  can  be  said  of  its 


446  TEXT-BOOK  OF  HYGIENE. 

comparative    prevalence?      How    is    it   usually    transmitted?      In   what   other 
ways  may  it  be  conveyed?     What  prophylactic  measures  are  indicated? 

\^niat  are  some  of  the  serious  diseases  of  animals  communicable  to  man? 
What  is  sheep-pock,  and  what  is  its  peculiarity  when  inoculated  upon  human 
beings  ? 

What  is  actinomycosis?  What  are  some  of  the  synonyms?  To  what  is 
it  due? 

In  what  two  forms  does  tuberculosis  oecvir  in  cattle?  Is  it  common 
among  them?  How  is  it  related  to  human  tuberculosis?  How  may  it  be 
transmitted  to  man?  What  precautions  should  be  enforced  to  prevent  this 
transmission? 

What  is  rabies?  How  is  it  transmitted?  Where  is  the  contagium  con- 
tained? Where  does  the  poison  of  greatest  virulence  reside?  How  may  the 
virus  be  cultivated,  and  what  changes  take  place  in  it?  How  may  immunity 
against  the  disease  be  produced?  Who  discovered  and  advocated  this  method 
of  inoculation? 

What  is  anthrax?  What  are  some  of  its  synonyms?  To  what  is  it 
due?  How  may  it  be  transmitted?  What  are  the  measures  of  prophylaxis 
against  it,  both  for  man  and  animals  ? 

Wiiat  is  glanders?  To  what  is  it  due?  How  may  infection  occur?  What 
should  be  done  with  animals  sick  with  this  disease?  What  else  should  be 
done? 


CHAPTER  XVIII. 

ANTISEPTICS,  DISINFECTANTS  AND  DEODORANTS. 

Much  confusion  exists  in  the  poj)ular  mind,  and  even  among 
physicians,  as  to  the  exact  meaning  of  the  terms  at  the  head  of  this 
chapter.  By  many  they  are  used  synonymously,  and  hence  frequently 
give  rise  to  ambiguity  and  misunderstanding. 

Antisepsis,  which  is  so  frequently  confounded  with  disinfection, 
should  be  more  accurately  defined  than  is  usual  by  writers.  An  anti- 
septic is  an  agent  which  retards,  prevents,  or  arrests  putrefaction, 
decay,  or  fermentation.  It  does  not  necessarily  destroy  the  vitality  of 
the  organisms  upon  which  these  processes  depend.  An  antiseptic  may 
also  arrest  the  development  of  the  organisms  which  cause  infectious 
diseases,  and  may  hence  be  used  as  a  preventive  of  such  diseases.  But 
antiseptics  do  not  destroy  the  life  of  disease-germs,  and  hence  cannot 
be  relied  upon  when  such  organisms  are  present. 

By  disinfection,  in  the  proper  and  restricted  use  of  the  term,  is 
meant  the  destruction  of  the  specific  infectious  material  which  causes 
infectious  diseases.  If  the  view  is  accepted  that  all  infectious  diseases 
are  due  to  micro-organisms  or  germs,  then  a  disinfectant  is  equivalent 
to  a  germicide.  In  sanitary  practice  and  experimental  investigations 
this  view  is,  in  fact,  adopted.  In  testing  the  action  of  various  disin- 
fecting agents  upon  infectious  material,  the  biological  test  is  the  one 
universally  relied  upon  by  experimenters,  and  no  observations  upon 
disinfection  based  upon  chemical  tests  alone  would  be  accepted  by 
sanitarians  as  conclusive.  It  may  therefore  be  assumed  for  practical 
purposes  that  no  agent  can  be  accepted  as  a  disinfectant  if  it  is  not 
also  a  germicide.  From  this  it  follows  that  disinfection,  to  be  trust- 
worthy, must  be  thorough.  "There  can  be  no  partial  disinfection  of 
infectious  material;  either  its  infectious  power  is  destroyed  or  it  is 
not.  In  the  latter  case  there  is  a  failure  to  disinfect."^  Obviously, 
also,  there  can  be  no  disinfection  in  the  absence  of  infectious  material. 
Fecal  discharges,  a  diseased  body  or  corpse,  clothing,  bedding,  an 
apartment,  a  ship,  or  a  hospital  ward  may  or  may  not  be  infected.  In 
the  former  case  we  may  speak  of  disinfecting  them;  in  the  latter  it 
would  be  an  inappropriate  use  of  the  word. 


"•Roport  of  Committee  on  Disinfectants  of  the  American  PTiblic  Health 
Association,  p.  236. 

(447) 


448 


TEXT-BOOK  OF  HYGIENE. 


Confusion  is  also  liable  to  arise  by  considering  disinfectants  and 
deodorizers  as  synonymous.  Deodorants  merely  remove  the  offensive 
odors,  and  may  not  possess  any  disinfecting  power  whatever.  Thus, 
one  of  the  most  efficient  disinfectants  at  our  command  (mercuric 
chloride)  is  not  a  deodorizer  at  all,  except  by  preventing  putrefaction. 
On  the  other  hand,  some  of  the  most  effective  deodorants  have  only  a 
subordinate  position  in  the  scale  of  disinfectants. 

Careful  investigations  have  sho'WTi  that  there  is  a  wide  divergence 
between  various  disinfecting  agents  in  their  influence  upon  disease- 
germs,  some  being  efficient  in  high  dilutions,  while  others  require  to 
be  brought  in  contact  with  the  germs  in  great  concentration.  For 
example,  mercuric  chloride  will  act  as  an  efficient  poison  to  certain 
disease-germs  (anthrax  spores)  in  the  proj)ortion  of  1  to  1000,  while 
zinc  chloride  must  be  used  in  the  proportion  of  1  to  5  (or  30  per  cent.). 

It  has  been  further  discovered  that  different  disease-germs  pre- 
sent varying  resisting  power  to  the  same  disinfecting  agent,  some 
being  easily  destroyed,  while  others  are  much  more  resistant.  For 
example,  the  following  table  shows  a  number  of  experiments  made 
by  Dr.  Meade  Bolton  for  the  American  Committee  on  Disinfectants : — 


Table  LVII. 

Organism. 

Chloride  of 
Lime. 

Mercuric 
Chloride. 

Carbolic  Acid. 

Typlioid  bacillus 

Cholera  spirillum      .... 
Anthrax  spores 

Staphylococcus  aureus .     .     . 
Staphylococcus  citreus       .     . 
Staphylococcus  albus    .     ,     . 

1 : 2000 
1 : 2000 
1:100 

1:200 

1:50 

1:200 

1  :  10,000 
1 :  10,000 
1:1000 

1:100 
1:100 
1:50 

(Uncertain.) 
1:100 
1:100 
1:100 

Assuming  that  infectious  diseases  are  caused  by  micro-organisms, 
and  that  these  are  different  from  the  micro-organisms  of  ordinary 
decay  or  putrefaction,  it  can  be  readily  understood  that  the  processes 
of  organic  decomposition  may  themselves  act  as  disinfectants.  It  is 
known,  for  example,  that  when  a  fermenting  liquid  putrefies,  the 
organisms  of  fermentation  disappear  and  give  place  to  the  organisms 
of  putrefaction  (bacterium  termo,  etc.).  So,  likewise,  the  bacilli  of 
anthrax  and  of  tuberculosis  are  killed  by  the  putrefactive  process,  if 
this  takes  place  in  the  absence  of  free  oxygen.  Furthermore,  the 
reproduction   of  organisms   of  a   certain  kind   ceases   when   certain 


ANTISEPTICS,  DISINFECTANTS  AND  DEODORANTS.  449 

chemical  changes  take  place  in  their  environment.  Fermentation 
in  a  saccharine  liquid  ceases  and  the  ferment-organisms  die  when  che 
accumulation  of  the  product  of  the  fermentation  (alcohol)  has 
reached  a  certain  proportion,  although  there  may  still  be  undecom- 
posed  sugar  present.  In  like  manner  it  is  intelligible  that  the  pro- 
ducts oi  micro-organisms  may  eventually  destroy  their  producers,  and 
so  place  a  limit  to  the  morbid  process.  The  specific  cause  of  small- 
pox, yellow  fever,  cholera,  and  similar  infectious  diseases  is  rapidly 
destroyed  when  decomposition  of  the  corpses  of  those  dead  with  such 
diseases  sets  in.  Hence,  the  reason  why  infectious  diseases  are  not 
spread  from  cemeteries. 

From  the  foregoing  it  may  be  gathered  that  disinfection  consists 
chiefly  in  a  struggle  against  organized  disease-germs.-  As,  how- 
ever, experiments  and  observations  have  shown  that  the  life-history 
of  disease-germs  varies  with  the  different  organisms  involved,  it  be- 
comes evident  that  specific  directions  concerning  disinfection  can  be 
given  only  when  the  life-history  of  the  specific  organism  is  known. 

The  American  Committee  on  Disinfectants,  to  whose  work  refer- 
ence has  already  been  made,  divides  disinfectants  into  two  classes: 
those  efficient  for  the  destruction  of  infectious  material  containing 
spores,  and  those  which  will  destroy  infectious  material  only  in  the 
absence  of  spores.  The  recommendations  of  the  committee,  covering 
not  only  the  appropriate  disinfectant  to  be  used  for  the  destruction 
of  the  organisms,  but  also  the  conditions  under  which  the  agent 
should  be  used,  are  as  follow : — - 

The  most  useful  agents  for  the  destruction  of  spore-containing  infectious 
material   are: — 

1.  Fire.     Complete  destruction  by  burning. 

2.  Steam  under  pressure.     105°  C.   (221°  F. )   for  ten  minutes. 

3.  Boiling  in  water  for  half  an  hour. 

4.  Chlorinated  lime.''     A  4-per-cent.  solution. 

5.  Mercuric  chloride.    A  solution  of  1  to  500. 

For  the  destruction  of  infectious  material  which  owes  its  infecting  power 
to  the  presence  of  micro-organisms  not  containing  spores,  the  committee  rec- 
ommends:— 

1.  Fire.     Complete   destruction   by  burning. 

2.  Boiling  in  water  for  ten  minutes. 

.3.  Dry  heat.     110°  C.    (230°  F.)   for  two  hours. 
4.  Chlorinaled  lime.''     A  2-per-cent.  solution. 


^Mueller  und  Falk,  in  Roalcncycloposdie  d.  ges.  Heilk.,  Bd.  IV.,  p.  62. 
^Sliould  contain  at  IcaHt  25  per  cent,  of  available  chlorine. 

29 


450  TEXT-BOOK  OF  HYGIENE. 

5.  Solution  of  chlorinated  soda.*     A  10-per-cent.  solution. 

6.  Mercuric  chloride.     A  solution  of  1  to  2000. 

7.  Sulphur  dioxide.     Exposure  for  twelve  hours  to  an  atmosphere  con- 
taining at  least  4  volumes  per  cent,  of  this  gas  in  presence  of  moisture.^ 

8.  Carbolic  acid.    A  5-per-cent.  solution. 

9.  Sulphate  of  copper.     A  5-per-cent.  solution. 
10.  Chloride  of  zinc.     A  10-per-cent.  solution. 

The  committee  would  make  the  following  recommendations  with  refer- 
ence to  the  practical  application  of  these  agents  for  disinfecting  purposes:  — 

For  Excreta. 

(a)   In  the  sick-room: —  — 

1.  Chlorinated  lime   in   solution,   4  per  cent. 

In  the  absence  of  spores: — 

2.  Carbolic  acid  in  solution,  5  per  cent. 

.3.  Sulphate  of  copper  in  solution,  5   per  cent. 

fh)  In  privy -vaults :  — 

1.  Mercuric  chloride  in  solution,  1  to  500.* 

2.  Carbolic  acid  in  solution,  5  per  cent. 

fc)   For  the  disinfection  and  dcodorization  of  the  surface  of  masses  of 
organic  material  in  privy- vaults,  etc.: — 
Chlorinated  lime  in  powder. 

For  Clothing,  Bedding,  etc. 

(a)  Soiled  underclothing,  bed-linen,  etc.: — 

1.  Destruction  by  fire,  if  of  little  value. 

2.  Boiling  for  at  least  half  an  hour. 

3.  Immersion  in  a  solution  of  mercuric  chloride  of  the  strength 

of  1  to  2000  for  four  hours. 

4.  Immersion   in   a   2-per-cent.   solution   of   carbolic  acid   for  four 

hours. 

fb)  Outer  garments  of  wool  or  silk,  and  similar  articles,  which  would 
be  injured  by  immersion  in  boiling  water  or  in  a  disinfecting  solution:  — 

1.  Exposure   in   a   suitable   apparatus  to   a  current   of   steam   for 

ten  minutes. 

2.  Exposure  to  dry  heat  at  a  temperature  of   110°   C.    (230°   F. ) 

for  two  hours. 


*  Should  contain  at  least  3  per  cent,  of  available  chlorine. 

^This  will  require  the  combustion  of  between  1%  to  2  kilogrammes  of 
sulphur  for  every  28  cubic  metres  of  air-space.  The  vaporization  of  liquid 
sulphur-dioxide  can  be  more  accurately  regulated. 

"The  addition  of  an  equal  quantity  of  potassium  permanganate  as  a  de- 
odorant, and  to  give  color  to  the  solution,  is  to  be  recommended. 


ANTISEPTICS,  DISINFECTANTS  AND  DEODORANTS.  45I 

(c)  Mattresses  and  blankets  soiled  by  the  discharges  of  the  sick:  — 

1.  Destruction  by  fire. 

2.  Exposure  to  superheated  steam    (105°   C.    =221°   F. )    for  ten 

minutes.      (Mattresses   to  have  the  cover  removed  or   freely 
opened. ) 

3.  Immersion  in  boiling  water  for  half  an  hour. 

Furniture  and  Articles  of  Wood,  Leather,  and  Porcelain. 

Washing,  several  times  repeated,  with  solution  of  carbolic  acid,  2  per 
cent. 

For  the  Person. 

The  hands  and  general  surface  of  the  body  of  attendants  of  the  sick, 
and  of  the  convalescents,  should  be  washed  with — 

1.  Solution  of  chlorinated  soda  diluted  with  nine  parts  of  water 

(1  to  10). 

2.  Carbolic  acid,  2-per-cent.  solution. 

3.  Mercuric  chloride,  1  to  1000. 

For  the  Dead. 

Envelop  the  body  in  a  sheet  thoi'oughly  saturated  with — 

1.  Chlorinated  lime  in  solution,   4  per  cent. 

2.  Mercuric  chloride   in   solution,   1   to   500. 

3.  Carbolic  acid  in  solution,  5  per  cent. 

For  the  Sick=room  and  Hospital  Wards. 

(a)  While  occupied,  wash  all  surfaces  with — 

1.  Mercuric  chloride  in  solution,    1   to    1000. 

2.  Carbolic  acid  in  solution,  2  per  cent. 

(b)  When  vacated: — 

Fumigate  with  sulphur  dioxide  for  twelve  hours,  burning  at  least  11/2 
kilogrammes  sulphur  for  every  28  cubic  metres  of  air-space  in  the  room; 
then  wash  all  surfaces  with  one  of  the  above-mentioned  disinfecting  solutions, 
and  afterward  with  soap  and  hot  water;  finally  throw  open  doors  and  win- 
dows and  ventilate  freely. 

For  Merchandise  and  the  Mails. 

The  disinfection  of  merchandise  and  of  the  mails  will  only  be  required 
under  exceptional  circumstances;  free  aeration  will  usually  be  sufficient. 
If  disinfection  seems  necessary,  fumigation  with  sulphur  dioxide  will  be  the 
only  practicable  method  of  accomplishing  it  without  injury. 

Rags. 

(a)  Rags  which  have  been  used  for  wiping  away  infectious  discharges 
should  at  once  lie  burnt-d. 


452  TEXT-BOOK  OF  HYGIENE. 

fb)  Rags  collected  for  the  paper-makers  during  the  prevalence  of  an 
epidemic  should  be  disinfected,  before  they  are  compressed  in  bales,  by — 

1.  Exposure   to   superheated   steam    (105°    C.  =  221°    F. )    for   ten 

minutes. 

2.  Immersion   in  boiling  water   for   half  an  hour. 

Ships. 

fa)  Infected  ships  at  sea  should  be  washed  in  every  accessible  place,  and 
especially  localities  occupied  by  the  sick,  with — 

1.  Solution  of  mercuric  chloride,  1  to  1000. 

2.  Solution  of  carbolic   acid,   2   per  cent. 

The  bilge  should  be  disinfected  by  the  liberal  use  of  a  strong 
solution   of   mercuric   chloride. 

(b)  Upon  arrival  at  a  quarantine  station,  an  infected  ship  should  at 
once  be  fumigated  with  sulphurous-acid  gas,  using  li/4  kilogrammes  of  sul- 
phur for  every  28  cubic  metres  of  air-space;  the  cargo  should  then  be  dis- 
charged on  lighters;  a  liberal  supply  of  the  concentrated  solution  of  mercuric 
chloride  (1  to  32)  should  be  thrown  into  the  bilge,  and  at  the  end  of  twenty- 
four  hours  the  bilge-water  should  be  pumped  out  and  replaced  with  pure  sea- 
water;  this  should  be  repeated.  A  second  fumigation  after  the  removal  of 
the  cargo  is  recommended.  All  accessible  surfaces  should  be  washed  with  one 
of  the  disinfecting  solutions  heretofore  recommended,  and  subsequently  with 
soap  and  hot  water. 

For  Railway=cars. 

The  directions  given  for  the  disinfection  of  dwellings,  hospital  wards, 
and  ships  apply  as  well  to  infected  railway-cars.  The  treatment  of  excreta 
with  a  disinfectant  before  they  are  scattered  along  tlie  tracks  seems  desirable 
at  all  times,  in  view  of  the  fact  that  they  may  contain  infectious  germs. 
During  the  prevalence  of  an  epidemic  of  cholera  this  is  imperative.  For  this 
purpose  the  standard  solution  of  chlorinated  lime  is  recommended. 

From  the  foregoing  it  would  appear  that  heat,  chlorinated  lime, 
mercuric  chloride,  solution  of  chlorinated  soda  ( Laharraque's  solu- 
tion), carholic  acid,  sulphate  of  copper,  zinc  chloride,  and  sulphur 
dioxide  (sulphur  fumes)  are  the  most  generally  available  disinfec- 
tants. 

The  following  "general  directions"  for  the  practical  application 
of  disinfection  are  given  by  the  committee : — 

Disinfection  of  Excreta,  etc.— The  infectious  character  of  the  dejections 
of  patients  suffering  from  cholera  and  typhoid  fever  is  well  established;  and 
this  is  true  of  mild  cases  an^  of  the  earliest  stages  of  these  diseases,  as  well 
as  of  severe  and  fatal  cases.  In  cholera,  diphtheria,  yellow  fever,  and  scarlet 
fever  all  vomited  material  should  also  be  looked  upon  as  infectious.     And  in 


ANTISEPTICS,  DISINFECTANTS  AND  DEODORANTS.  453 

tuberculosis,  diphtheria,  scarlet  fever,  and  infectious  pneumonia  the  sputa  of 
the  sick  should  be  disinfected  or  destroyed  by  fire.  It  seems  advisable,  also,  to 
treat  the  urine  of  patients  sick  with  an  infectious  disease  with  one  of  the  dis- 
infecting solutions  below  recommended. 

Chloride  of  lime,  or  bleaching  powder,  is  perhaps  entitled  to  the  first 
place  for  disinfecting  excreta,  on  account  of  the  rapidity  of  its  action.  The 
following  standard  solution  is  recommended:  — 

Dissolve  chloride  of  lime  (chlorinated  lime,  bleaching  powder)  of  the 
best  quality''  in  pure  wafer  in  the  proportion  of  G  ounces  to  the  gallon  (45 
grammes   to  the   litre). 

Use  1  quart  (1  litre)  of  this  solution  for  the  disinfection  of  each  dis- 
charge in  cholera,  typhoid  fever,  etc.«  Mix  well,  and  leave  in  the  vessel  for 
at  least  one  hour  before  throwing  into  privy-well  or  water-closet.  The  same 
directions  apply  for  the  disinfection  of  vomited  matters.  Infected  sputum 
should  be  discharged  directly  into  a  cup  half  full  of  the  solution.^'  A  5-per 
cent,  solution  of  carbolic  acid  may  be  used  instead  of  the  chloride-of-lime 
solution,  the  time  of  exposure  to  the  action  of  the  disinfectant  being  four 
hours. 

Disinfection  of  the  Person. — The  surface  of  the  body  of  a  sick  person 
or  of  his  attendants,  when  soiled  with  infectious  discharges,  should  be  at 
once  cleansed  with  a  suitable  disinfecting  agent.  For  this  purpose,  solution 
of  chlorinated  soda  (liquor  sodee  chlorinatte — Labarraque's  solution)  diluted 
with  9  parts  of  water,  or  the  standard  solution  of  chloride  of  lime  diluted 
with  3  parts  of  water,  may  be  used.  A  2-per-cent.  solution  of  carbolic  acid 
is  also  suitable  for  this  purpose,  and  under  proper  medical  supervision  the 
use  of  a  solution  of  corrosive  sublimate    (1  to   1000)    is  to  be 'recommended. 

In  diseases  like  small-pox  and  scarlet  fever,  in  which  the  infectious  agent 
is  given  off  from  the  entire  surface  of  the  body,  occasional  ablutions  with  the 
above-mentioned  solution  of  chlorinated  soda  are  recommended. 

In  all  infectious  diseases  the  body  of  the  dead  should  be  enveloped  in 
a  sheet  saturated  with  the  standard  solution  of  chlorinated  lime,  or  with  a 
5-per-cent.  solution  of  carbolic  acid,  or  a  1  to  500  solution  of  corrosive  sub- 
limate. 

Disinfection  of  Clothing. — Boiling  for  half  an  hour  will  destroy  the 
vitality  of  all  known  disease-germs,  and  there  is  no  better  way  of  disinfecting 
clothing  or  bedding  which  can  be  washed  than  to  put  it  through  the  ordinary 
operations  of  the  laundry.  No  delay  should  occur,  however,  between  the  time 
of  removing  soiled  clothing  from  the  person  or  bed  of  the  sick  and  its  im- 
mersion in  boiling  water,  or  in  one  of  the  following  solutions  until  this  can 
be  done: — 


'Good  chloride  of  lime  should  contain  at  least  2.5  per  cent,  of  available 
chlorine.  Eecently  nascent  chlorine  for  disinfecting  purposes  has  been  ob- 
tained on  a  large'  scale  by  the  electrolysis  of  sea-water. 

"  For  a  very  copious  discharge  use  a  larger  quantity. 

"Rffcntly  a  small  spitting-cup  made  of  stiff  paper  has  been  iiitrodiiccd 
especially  for'  the  use  of  consumptives.  The  cup  is  carried  about  by  the 
patient  or  kc])t  witliin  reach.  \Yhen  the  cup  has  been  in  use  for  a  time,  and 
licfor!!  tlie  sputa  can  bccoinc  dcsiccafcil,  it   \^  liirown   into  the  fire  and  burned. 


454  TEXT-BOOK  OF  HYGIENE. 

Corrosive  sublimate,  1  gramme  to  the  litre  (1  to  1000),  or  carbolic  acid 
(pure),  8  grammes  to  the  litre. 

The  articles  to  be  disinfected  must  be  thoroughly  soaked  with  the  dis- 
infecting solution  and  left  in  it  for  at  least  two  hours,  after  which  they  may 
be  wrung  out  and  sent  to  the  wash.^" 

Clothing  or  bedding  which  cannot  be  washed  should  be  disinfected  by 
steam  in  a  properly-constructed  disinfection  chamber.  In  the  absence  of  a 
suitable  steam  disinfecting  apparatus,  infected  clothing  and  bedding  should 
be  burned. 

Disinfection  of  the  8ick-room. — In  the  sick-room  no  disinfectant  can 
take  the  place  of  free  ventilation  and  cleanliness.  It  is  an  axiom  in  sanitary 
science  that  it  is  impracticable  to  disinfect  an  occupied  apartment  for  the 
reason  that  disease-germs  are  not  destroyed  by  the  presence  in  the  atmosphere 
of  any  known  disinfectant  in  respirable  quantity.  Bad  odors  may  be  neu- 
tralized, but  this  does  not  constitute  disinfection  in  the  sense  in  which  the 
term  is  here  used.  These  bad  odors  are,  for  the  most  part,  an  indication  of 
want  of  cleanliness  or  of  proper  ventilation,  and  it  is  better  to  turn  con- 
taminated air  out  of  the  window  or  up  the  chimney  than  to  attempt  to  purify 
it  by  the  use  of  volatile  chemical  agents,  such  as  carbolic  acid,  chlorine,  etc., 
which  are  all  more  or  less  offensive  to  the  sick,  and  are  useless  so  far  as 
disinfection — properly  so  called — is  concerned. 

When  an  apartment  which  has  been  occupied  by  a  person  sick  with  an 
infectious  disease  has  been  vacated,  it  should  be  disinfected.  The  object  of 
disinfection  in  the  sick-room  is  mainly  the  destruction  of  infectious  material 
attached  to  surfaces  or  deposited  as  dust  upon  window-ledges,  in  crevices,  etc. 
If  the  room  has  been  properly  cleansed  and  ventilated  while  still  occupied  by 
the  sick  person,  and  especially  if  it  was  stripped  of  carpets  and  unnecessary 
furniture  at  the  outset  of  his  attack,  the  difficulties  of  disinfection  will  be 
greatly  reduced. 

All  surfaces  should  be  thoroughly  washed  with  the  standard  solution 
of  chloride  of  lime,  diluted  with  3  parts  of  water,  or  with  1  to  1000  solution 
of  corrosive  sublimate.  The  walls  and  ceiling,  if  plastered,  should  be  subse- 
quently treated  with  a  lime-wash.  Especial  care  must  be  taken  to  wash 
away  all  dust  from  window-ledges  and  other  places  where  it  may  have  settled, 
and  thoroughly  to  cleanse  crevices  and  out-of-the-way  places.  After  this 
application  of  the  disinfecting  solution,  and  an  interval  of  twenty-four  hours 
or  longer  for  free  ventilation,  the  floors  and  wood-work  should  be  well  scrubbed 
with  soap  and  hot  water,  and  this  should  be  followed  by  a  second,  more  pro- 
longed exposur  •  to  f  re&h  air,  admitted  through  open  doors  and  windows. 

As  an  additional  precaution,  fumigation  with  sulphurous-acid  gas  is 
to  be  recom'uended,  especially  for  rooms  which  have  been  occupied  by  patients 
Avith  small-pox,  scarlet  fever,  diphtheria,  typhus  fever,  and  yellow  fever.  But 
fumigation  with  sulphurous-acid  gas  alone,  as  commonly  practiced,  cannot  be 
relied  upon  for  disinfection  of  the  sick-room  and  its  contents,  including  bed- 
ding,  furniture,   infected  clothing,  etc.,   as   is  popularly  believed. 


^  "  Solutions   of   corrosive    sublimate    should   not   be   placed   in   metal   re- 

ceptacles, for  the  salt  is  decomposed  and  the  mercury  precipitated  by  contact 
with  copper,  lead,  or  tin.  A  wooden  tub  or  earthen  crock  is  a  suitable  re- 
ceptacle for  such  solutions. 


ANTISEPTICS,  DISINFECTANTS  AND  DEODORANTS.  455 

When  fumigation  is  practiced,  it  should  precede  the  general  washing 
with  a  disinfecting  solution  heretofore  recommended.  To  insure  any  results 
of  value,  it  will  be  necessary  to  close  the  :  partmsnt  to  be  disinfected  as  com- 
pletely as  possible  by  stopping  up  all  apertures  through  which  the  gas  might 
escape,  and  to  burn  not  less  than  3  pounds  of  sulphur  for  each  1000  cubic 
feet  {IV2  kilogrammes  to  28  cubic  metres)  of  air-space  in  the  room.  To 
secure  complete  combustion  of  the  sulphur,  it  should  be  placed,  in  the  form 
of  powder  or  small  fragments,  into  a  shallow  iron  pan,  which  should  be  set 
upon  a  couple  of  bricks  in  a  tub  partly  filled  with  water,  to  guard  against 
fire.  The  sulphur  should  be  thoroughly  moistened  with  alcohol  before  ignit- 
ing it." 

Disinfection  of  Privy-vaults,  Cess-pools,  etc. — When  the  excreta  (not 
previously  disinfected)  of  patients  with  cholera  or  typhoid  fever  have  been 
thrown  into  a  privy-vault  this  is  infected,  and  disinfection  should  be  resorted 
to  as  soon  as  the  fact  is  discovered,  or  whenever  there  is  reasonable  suspicion 
that  such  is  the  case.  It  will  be  advisable  to  take  the  same  precautions  with 
reference  to  privy-vaults  into  which  the  excreta  of  yellow  fever  have  been 
thrown,  although  we  do  not  definitely  know  that  this  is  infectious  material. 

For  this  purpose  the  standard  solution  of  chloride  of  lime  may  be  used 
in  quantity  proportioned  to  the  amount  of  material  to  be  disinfected,  but 
where  this  is  eonsiderabl*  it  will  scarcely  be  practicable  to  sterilize  the  whole 
mass.-  The  liberal  and  repeated  use  of  this  solution,  or  of  a  5-per-cent.  solu- 
tion of  carbolic  acid,  will,  however,  disinfect  the  surface  of  the  mass,  and  is 
especially  to  be  recommended  during  the  epidemic  prevalence  of  typhoid  fever 
or  of  cholera. 

All  ex  "osed  portions  of  the  vault,  and  the  wood-work  above  it,  should 
be  thoroughly  washed  down  with  the  disinfecting  solution.  Instead  of  the 
disinfecting  solutions  recommended,  chloride  of  lime  in  powder  may  be  daily 
scattered  over  the  contents  of  the  privy-vault. 

Disinfection  of  Ingesta. — It  is  well  established  that  cholera  and  typhoid 
fever  are  very  frequently,  and  perhaps  usually,  transmitted  through  the 
medium  of  infected  water  or  articles  of  food,  and  especially  milk.  Fortunately, 
we  have  a  simple  means  at  hand  for  disinfecting  such  infected  fluid.  This 
consists  in  the  application  of  heat.  The  boiling  temperature  maintained  for 
half  an  hour  kills  all  known  disease-ge^-ms.  So  far  as  the  germs  of  cholera, 
typhoid  fever,  and  diphtheria  are  concerned,  there  is  good  reason  to  believe 
that  a  temperature  considerably  below  the  boiling-point  of  water  will  destroy 
them.  But  in  order  to  keep  on  the  safe  side,  it  is  best  not  to  trust  anything 
short  of  the  boiling-point  (100°  C.  =  212°  F.)  when  the  object  is  to  disinfect 
food  or  drink  which  is  open  to  the  suspicion  of  containing  the  germs  of  any 
infectious  disease.  During  the  prevalence  of  an  epidemic  of  cholera  it  is  wall 
to  boil  all  water  for  drinking  purposes.  After  boiling,  the  water  may  be 
filtered,  if  necessary,  to  remove  sediment,  and  then  cooled  with  pure  ice  if 
desired. 


"Liquid  anliydrous  sulphur-dioxide  may  be  used,  and  will  probably  give 
better  results  than   combustion   of  sulphur. 


456  TEXT-BOOK  OF  HYGIENE. 

In  recent  years  formaldehyde  gas  has  taken  the  place  of  sulphur 
for  aerial  disinfection  of  rooms,  fomites,  etc.  The  following  is  freely 
quoted  from  a  circular  issued  by  the  Illinois  State  Board  of  Health : — 

Formaldehyde  (otherwise  known  as  methyl  aldehyde,  formic- 
aldehyde  and  "formalin")  exists  in  several  forms,  but  is  principally 
known  as  gas.  Its  germicidal  properties  were  not  recognized  until 
1886,  and  were  not  put  to  use  until  1890.  The  formaldehyde  gas  is 
the  vapor  of  wood  alcohol  v,diich  has  undergone  a  chemical  change. 
The  gas  is  produced  by  passing  the  vapor  of  wood  alcohol  over  plati- 
num or  platinized  carbon  in  an  incandescent  state.  Many  portable 
apparatus  for  the  production  of  formaldehyde  gas  directly  from  wood 
alcohol  have  been  devised  during  the  past  seven  or  eight  years,  but 
none  have  proved  satisfactory. 

The  aqueous  solution  of  formaldehyde  gas,  known  as  formalde- 
hyde or  formalin,  is  a  40-per-cent.  solution  of  the  formaldehyde  gas 
in  water.  Many  of  the  commercial  preparations  do  not  contain  40 
per  cent,  of  formaldehyde.  The  concentration  of  the  solution  can 
not  exceed  40  ^er  cent.  This  preparation,  if  properly  made,  is  a  pow- 
erful bactericide  and  is  preferable  to  corrosive  sublimate  as  a  germi- 
cide, cost  not  considered,  although  it  is  much  slower  in  action.  Sev- 
eral processes  have  been  devised  for  the  liberation  of  formaldehyde 
gas  from  its  watery  solution.  The  solution  when  exposed  to  the  air 
gives  off  a  considerable  quantity  of  the  gas,  especially  when  sprayed 
on  large  surfaces.  If  sprayed  on  b^.ankets  or  sheets,  or  articles  of 
clothing,  hung  in  the  room  or  on  the  walls,  the  liberation  of  the  gas 
will  be  so  rapid  as  to  compel  the  operator  to  leave  the  room.  These 
facts  have  given  rise  to  the  belief  that  exposure  of  the  gas  in  this 
manner  will  be  sufficient  to  cause  disinfection.  The  results,  however, 
do  not  confirm  this.  There  is  much  uncertainty  as  to  the  amount  of 
gas  which  is  evolved,  and  the  behavior  of  the  gas  is  at  times  very 
capricious. 

The  most  common  method  of  obtaining  formaldehyde  gas  from 
the  watery  solution  at  the  present  time  is  by  means  of  apparatus 
designed  to  regenerate  the  gas  by  boiling  the  solution  under  pressure. 
Many  generators  operating  on  this  principle  are  to  be  found  on  the 
market.  Several  of  these  are  complicated  machines  requiring  skill  to 
properly  operate.  As  some  of  the  generators  require  constant  atten- 
tion, it  has  been  found  necessary  to  place  them  outside  of  the  apart- 
ment being  disinfected  and  to  pass  the  gas  into  the  room  by  means  of 
a  tube  nm  through  a  keyhole.  The  diffusion  of  the  gas  produced  in 
this  way  is  slow,  jjarticularly  in  large  areas,  tending  to  concentration 


ANTISEPTICS,  DISINFECTANTS  AND  DEODORANTS.  457 

at  a  few  points  and  to  the  formation  of  paraformaldehyde.  This 
method  of  disinfection  cannot  be  recommended. 

With  the  Schering  method  of  disinfection,  which  consists  in  the 
rapid  evaporation  of  paraform  pastilles,  said  to  contain  100  per  cent, 
pure  formaldehyde,  many  tests  have  been  made  by  the  Illinois  State 
Board  of  Health  during  the  past  five  years.  The  results  were  gen- 
erally satisfactory,  when  the  gases  evolved  were  thoroughly  mixed 
with  the  watery  vapor.  This  method,  however,  is  expensive;  much 
care  must  be  used  in  the  working  of  the  generator,  and  it  has  been 
found  very  difficult  after  disinfection  to  rid  the  premises  of  the  gas. 
In  one  of  the  experiments  the  vapor  ignited.  The  experiments  were 
conducted  with  the  Schering  formalin  disinfector  (not  the  lamp) 
manufactured  by  Schering  &  Glatz,  Xew  York. 

Formaldehyde  candles,  which  are  composed  of  a  variable  amount 
of  paraformaldehyde,  pressed  in  cylindrical  form  in  a  tin  container, 
are  now  ofi^ered  to  ^Dhysicians  and  health  authorities  as  a  means  of 
disinfection.  It  is  claimed  that,  by  burning  the  paraform,  the  heat 
produced  causes  the  solid  to  revert  to  the  gaseous  form.  No  depend- 
ence whatever  should  be  placed  on  these  candles. 

The  evaporation  of  the  solution  of  formaldehyde  by  means  of 
heat  in  an  ordinary  kettle  is  one  of  the  simplest  methods  of  disin- 
fection with  formaldehyde,  and  as  a  result  has  proven  the  most 
effective.  This  is  termed  the  Breslau  method.  Many  health  authori- 
ties have  testified  to  its  efficiency  during  the  past  seven  years. 

While  the  results  obtained  with  some  of  the  methods  of  formalde- 
hyde disinfection  formerly  suggested  have  been  generally  satisfactory, 
failures  were  at  times  experienced  when  the  conditions  were  appar- 
ently ideal;  while  under  unfavorable  conditions  of  temperature  and 
humidit}',  ineffective  disinfection  was  of  frequent  occurrence. 

Eecently  an  exceedingly  simple  method  of  generating  the  gas  by 
pouring  formaldehyde  solution  over  the  crystals  of  potassium  perman- 
ganate in  an  open  vessel  has  been  suggested,  arid  gives  promise  of 
overcoming  the  objections  which  have  stood  in  the  way  of  the  more 
general  adoption  of  formaldehyde  as  a  disinfecting  agent.  This 
method  primarily  offered  the  advantages  of  absolute  simplicity  in 
operation,  requiring  no  special  apparatus  and  no  fire.  In  addition 
to  this,  exhaustive  experimental  work  has  demonstrated  that,  in  prac- 
tical disinfection,  the  method  is  unusually  efficient,  the  effectiveness 
seeming  to  depend  less  upon  the  conditions  of  humidity  and  tempera- 
ture than  that  of  any  other  method. 

The  only  apparatus  required  is  a  large,  open  vessel,  protected  by 


458  TEXT-BOOK  OF  HYGIENE. 

some  non-conductive  material  to  preserve  the  heat  within.  An  ordi- 
nary milk-pail,  set  into  a  pulp  or  wooden  bucket,  will  answer  every 
purpose,  although  a  special  container,  devised  for  physicians  and 
health  officers,  will  be  found  of  considerable  advantage.  This  con- 
tainer or  generator  consists  of  a  simply  constructed  tin  can  witli 
broad,  flaring  top.  -Its  full  height  is  151/^  inches,  the  height  to  the 
flaring  or  funnel-shaped  top  being  about  8  inches.  The  lower  or 
round  section  is  10  inches  in  diameter,  while  the  funnel  is  171^  inches 
in  diameter  at  the  top.  This  container  is  made  of  a  good  quality  of 
tin,  is  supplied  with  a  double  bottom  with  14-inch  air-space  between 
the  layers  of  tin,  and  is  entirely  covered  on  the  outside  with  asbestos 
paper.  The  asbestos  paper  and  double  bottom  serve  to  effectively 
retain  the  heat  which  is  generated  by  the  vigorous  chemical  reaction 
occurring  within  the  generator  and  which  is  essential  to  the  complete 
production  and  liberation  of  the  gas.  The  special  container  can  be 
made  by  any  tinner  of  ordinary  intelligence  and  costs  but  a  few 
dollars. 

With  the  room  sealed,  as  is  essential  to  any  form  of  aerial  disin- 
fection, the  crystals  of  potassium  permanganate  (S^/o  ounces  to  each 
1000  cubic  feet  of  air-space)  are  placed  in  the  container.  Over  this 
salt  is  poured  "formalin"  or  the  40-per-cent.  aqueous  solution  of  for- 
maldehyde (1  pint  for  every  1000  cubic  feet  of  air-space).  The  for- 
maldehyde gas  is  promptly  liberated  by  the  vigorous  chemical  reac- 
tion of  the  formalin  and  the  potassic  salt  and  rises  from  the  generator 
in  immense  volume  in  the  form  of  an  inverted  cone.  It  is  conse- 
quently essential  that  all  preparations  be  made  in  advance  and  that 
the  operator  leave  the  room  at  once  on  the  combination  of  the  two 
chemicals. 

The  doors  or  windows  of  exit  should  be  promptly  closed  and 
sealed  and  the  room  left  closed  for  at  least  six  hours. 

The  results  obtained  by  this  method  in  experiments  conducted  in 
the  laboratories  of  the  Illinois  State  Board  of  Health,  under  vary- 
ing atmospheric  conditions,  and  with  a  rather  wide  range  of  tempera- 
ture, prove  the  method  peculiarly  effective,  while  the  simplicity  of 
the  operation,  the  small  expense  of  the  apparatus  (in  fact,  its  success- 
ful operation  without  apparatus  of  any  kind,  if  necessary),  and  the 
moderate  cost  of  operation  serve  to  commend  it. 

However,  even  this  method  is  not  entirely  free  from  danger  of 
fire.  Dr.  C.  T.  White,  while  experimenting  on  disinfection,  observed 
that  in  some  instances  spontaneous  combustion  of  the  formaldehyde 
gas  takes  place  after  the  addition  of  the  formaldehyde  to  the  per- 


ANTISEPTICS,  DISINFECTANTS  AND  DEODORANTS. 


459 


manganate  of  potash.  Mr.  C.  H.  La  Wall,  who  investigated  this 
phenomenon,  ascribes  it  to  the  rapid  formation  of  heat  in  the  pres- 
ence of  organic  matter,  and  suggests  the  employment  of  small  quan- 
tities of  permanganate,  not  over  4  to  8  ounces  to  a  charge,  placed  in 
several  containers  surrounded  with  large  cones  containing  water. 
There  should  be  no  flame  in  the  room. 

The   following   substances   are   antiseptics,   but   in   the   strength 
given  cannot  be  depended  upon  as  disinfectants : — 


Table  LVIII. 

Thymol   1 :  80,000. 

Bichloride  of  mercury   1 :  40,000. 

Oil  of  mustard   1 :  33,000. 

Acetate  of  alumina 1 :  6310. 

Bromine 1 :  5597. 

Picric  acid 1 :  5000. 

Iodine   1 :  4000. 

Sulphuric  acid    1 :  800-1 :  3353. 

Permanganate  of  potassium 1 :  3000. 

Camphor     1 :  2500. 

Eucalyptol    ' 1 :  2500. 

Chromic  acid 1 :  2200. 

Chloride  of  aluminum   1 :  2000. 

Hydrochloric  acid 1 :  1700. 

Benzoic  acid    1 :  1439. 

Quinine 1 :  1000. 

Boric  acid    1 :  200-1 :  800. 

Salicylic  acid    1 :  200-1 :  800. 

Carbolic  acid   : 1 :  500. 

Sulphate  of  copper    1 :  400. 

Nitric  acid 1 :  400. 

Biborate  of  soda 1 :  200. 

Sulphate  of  iron  1 :  200. 

Creasote   1 :  200. 

Arsenious  acid    1 :  100. 

Pyrogallic  acid   1 :  62. 

Tr.  chloride  of  iron 1 :  25. 

Alcohol 40  to  95  per  cent. 


The  agents  mentioned  in  the  above  list  may  all  be  used  with 
satisfactory  results  in  surgical  and  obstetrical  practice  as  antiseptics, 
hut  it  must  be  borne  in  mind  that  the  great  danger  in  treating  wounds 
comes  from  carrying  infectious  particles  to  them  in  the  hands  or  in- 
struments of  the  operator.  In  order  to  render  these  aseptic  the  most 
tboroiigh  measures  of  disin  feed  ion,  such  as  heat,  strong  chemical  dis- 


460  TEXT-BOOK  OF  HYGIENE. 

infectants,  and  physical  as  well  as  chemical  and  biological  cleanliness 
are  indicated.  In  a  surgical  wound,  or  in  the  vagina  and  uterus  of  the 
parturient  woman,  the  use  of  antiseptics  is  entirely  secondary  to  dis- 
infection, under  which  may  primarily  be  understood  rigid  cleanliness. 

In  public  and  private  sanitation,  antiseptics  have,  as  in  prac- 
tical surgery,  a  subordinate  importance. 

Deodorizers  are  sometimes  useful  in  sanitary  practice,  but  care 
must  be  taken  not  to  look  upon  deodorization  as  equivalent  to  disin- 
fection. Among  the  most  useful  deodorizers  are  chloride  of  zinc, 
chloride  of  lime,  permanganate  of  potassium,  and  a  number  of  the 
agents  mentioned  in  Table  LYIII. 


QUESTIONS  TO  CHAPTER  XVIII. 
ANTISEPTICS,   DISINFECTANTS,   AND   DEODORANTS. 

What  is  an  antiseptic?  How  may  it  be  used?  Is  it  necessarily  a  dis- 
infectant? Why?  Is  a  disinfectant  an  antiseptic?  Why?  Why  must  disin- 
fection be  thorough  to  be  of  any  value?  What  is  necessary  that  there  may  be 
disinfection?     How  is  the  term  often  popularly,  but  incorrectly,  used? 

What  is  the  essential  difference  between  a  disinfectant  and  a  deodorant? 
What  is  a  germicide?  What  is  the  true  test  of  the  value  of  a  disinfectant? 
Have  deodorants  as  such  any  real  sanitary  value?  How  do  disinfectants  differ 
in  relation  to  disease-germs?  How  do  the  latter  differ  in  relation  to  the 
former?  How  may  the  products  of  putrefaction,  fermentation,  or  decay  act 
as  disinfectants?  How  may  the  products  of  the  disease-germs  themselves  act 
as  antiseptics  or  disinfectants? 

How  may  disinfectants  be  classified?  What  are  the  most  useful  agents 
for  destroying  spore-containing  infectious  material?  How  should  these  be 
used?  What  do  we  call  disinfection  by  fire  or  heat?  What  agents  may  be 
used  to  disinfect  infectious  matter  not  containing  spores?  Which  are  most 
efficacious?  What  is  an  essential  factor  in  the  successful  use  of  all  disin- 
fectants ? 

In  what  diseases  may  the  excreta  be  infected?  What  disinfectants  may 
be  used  for  excreta  in  the  sick-room?  In  cess-pools?  Why  is  mercuric  chlo- 
ride not  so  efficacious  here?  What  is  the  objection  to  the  use  of  carbolic  acid 
in  typhoid  fever?  Why  is  chlorinated  lime  such  a  valuable  disinfectant? 
How  much  chlorine  should  it  contain?  How  should  it  be  prepared?  What  is 
"milk  of  lime,"  and  what  value  has  it  as  a  disinfectant  for  excreta? 

How  may  soiled  underclothing,  bed-linen,  etc.,  be  disinfected?  How  long 
shovild  clothing  be  boiled  in  order  to  thoroughly  disinfect  it  ?  How  may  cloth- 
ing that  would  be  harmed  by  immersion  or  chemicals  be  disinfected?  What 
will  be  the  effects  on  clothing  of  chlorine  and  stilphur  gases?  How  may  mat- 
tresses, blanketSj  etc.,  be  disinfected?  How  long  should  the  active  process 
require  ? 

What  are  some  of  the  best  disinfectants  for  use  on  the  person?  How 
may  the  danger  of  infection  from  a  case  of  scarlet  fever,  small-pox,  etc.,  be 
lessened?  How  should  the  bodies  of  those  dead  of  infectious  diseases  be 
cared  for? 

What  can  be  done  in  the  way  of  disinfection  during  the  occupancy  of 
the  sick-room?  What  are  the  only  disinfectants  available?  What  value  will 
deodorants  have  here  ?  What  method  is  to  be  followed  as  soon  as  the  sick- 
room is  vacated?     Describe  in  detail. 

How  may  suspected  merchandise  and  the  mails  be  purified?  What 
treatment  should  rags,  etc.,  undergo?  What  is  the  method  prescribed  for 
the  disinfection  of  a  ship?     For  railway-cars?      (See  chapter  on  Quarantine.) 

How  may  articles  of  food  and  drink  be  made  sterile  and  safe  for  use? 

How  are  antiseptics  and  disinfectants  to  be  used,  and  for  what  purpose, 
in  surgical  and  obstetrical  practice? 

What  is  formaldehyde?  What  is  the  usual  method  of  using  formalde- 
hyde?    What  is  the  best  method? 

(461) 


CHAPTER  XIX. 

VITAL  STATISTICS. 

The  registration  of  vital  statistics  comprises  the  recording  of 
the  births,  marriages,  deaths,  and  diseases  of  a  city,  State,  or  nation. 
The  facts  thus  secured  must  be  properly  classified  and  studied,  for  in 
no  other  way  can  a  knowledge  of  the  health  of  the  inhabitants  of 
such  communities  be  obtained,  and  a  real  test  is  thus  also  furnished 
of  the  actual  efficiency  of  sanitary  undertakings.  We  may,  indeed, 
study  disease  both  by  observation  and  experiment,  thus  learning  that 
some  maladies  are  more  preventable  than  others  and  discovering  their 
causes  and  means  of  jDrevention ;  and  it  is  also  true  that  for  smaller 
or  special  communities,  such  as  armies,  navies,  schools,  or  special 
classes  of  workmen,  the  health  status  may  be  obtained  by  direct 
methods  but  for  large  communities  this  is  clearly  impracticable,  and 
the  sanitarian  is  obliged  to  depend  upon  the  census  and  the  above- 
mentioned  registration. 

The  census  is  the  count  of  its  population  which  every  civilized 
country  makes  at  certain  intervals,  its  returns  also  including  particu- 
lars as  to  age,  sex,  race,  occupation,  etc.  From  the  sanitarian's 
standpoint  the  age-record  is,  next  to  the  population,  the  most  im- 
portant return,  for  the  death-rate  varies  most  according  to  age.  In 
this  country  the  census  now  furnishes  various  data  for  localized  "san- 
itary districts,"  which  may  be  even  smaller  than  city  wards,  and  these 
data  afford  the  basis  of  comparison  for  variations  in  different  parts 
of  the  same  city  and  at  different  periods. 

The  records  of  births,  marriages,  deaths,  and  diseases  are  obtained 
from  the  registration  bureau,  having  been  furnished  the  latter  by 
duly  authorized  persons.  The  duty  of  registration  should  devolve 
upon  the  sanitary  administration,  such  as  the  local  or  State  board  of 
health,  this  being  the  most  appropriate  medium  for  the  collection 
of  the  information  in  question,  while  the  individual  returns  should 
obviously  be  made  to  the  bureau  by  the  attending  physician  in  each 
case.  And,  as  these  returns  should  be  as  accurate  as  possible,  espe- 
cially as  regards  the  diagnosis  of  preventable  diseases  and  the  deter- 
mination of  the  causes  of  death,  both  primary  and  secondary,  it  is 
one  of  the  reasons  why  the  State  should  carefully  determine  the 
(462) 


VITAL  STATISTICS.  46?> 

qualifications  of  the  physicians  whom  it  allows  to  practice  within  its 
confines. 

From  a  sanitary  point  of  view,  the  most  important  object  of  a 
registration  of  vital  statistics  is  to  "give  warning  of  the  undue  increase 
of  disease  or  death  presumed  to  be  due  to  preventable  causes,  and  to 
indicate  the  localities  in  which  sanitary  efi^ort  is  most  desirable  and 
most  likely  to  be  of  use."^ 

It  should  be  remembered  that  the  following  fundamental  prin- 
ciples that  underlie  all  statistical  inquiries  must  be  considered  in 
the  examination  and  analysis  of  any  records  or  reports  of  the  kind 
in  question  :— 

1.  The  numerical  units  with  which  the  inquiry  has  to  do  must 
be  constant,  definite,  and  precise  in  character;  if  any  lack  these 
qualities,  such  should  be  omitted  altogether.  Hence  the  care  that 
should  be  observed  in  the  diagnosis  of  all  cases. 

2.  Groups  of  the  numerical  units  must  be  so  arranged  that  no 
unit  is  in  more  than  one  group  at  a  time,  and  so  that  there  can  be 
no  question  as  to  the  group  in  which  each  unit  belongs.  This  is  com- 
paratively simple  where  the  grouping  regards  only  the  age,  sex,  race, 
etc.,  but  the  difficulty  increases  with  the  complexity  of  facts  and  re- 
quires special  talent  to  properly  analyze  and  develop  all  possible 
features. 

3.  There  must  be  a  standard  to  express  the  relation  of  each 
group  to  the  sum  of  the  individual  unit.  This  is  usually  100,  1000, 
or  some  multiple  of  either. 

4.  The  relation  of  each  group  to  the  total  units  is  not  a  con- 
stant one  unless  all  the  factors  which  govern  that  relation  are  fixed 
and  invariable — a  condition  which  obviously  does  not  obtain  in  vital 
statistics.  The  limit  of  variation  in  the  relation  of  the  component 
groups  to  the  total,  in  two  or  more  similar  series,  may,  however,  be 
expressed  mathematically,  and  the  variation  itself  will  be  found  to 
diminish  as  the  sum  of  individual  units  increases.  Thus  if,  in  the 
formula  m  -\-  n  =  q,  m  be  the  number  of  units  in  one  group  and  n 
the  number  in  the  other,  the  limit  of  variation  will  be  indicated  by  the 
expression  2  "^  '^-^-  ;  or,  again,  the  relative  value  of  two  or  more 
series  is  as  the  square  root  of  the  number  of  units  in  the  respective 
series. 

The  arithmetical  mean  is  often  used  in  vital  statistics,  and  this 


'  J.  S.  Billinf,'H,  "Rej^istration  of  Vital  Statistics,"  American  Journal  of 
the  Medical   Sciences,  vol.  Ixxxv,  p.  37. 


464  TEXT-BOOK  OF  HYGIENE. 

will  always  approximate  the  invariable  if  the  number  of  units  is 
sufficient,  but  it  must  be  remembered  that  the  relation  expressed  by 
the  average  in  one  case  cannot  be  predicated  positively  of  any  other. 
As  Dr.  Guy  says,  "Averages  are  numerical  expressions  of  probabilities ; 
extreme  values  are  expressions  of  possibilities." 

The  grajihic  representation  of  statistical  results  is  of  advantage, 
since  it  brings  their  salient  features  clearly  before  the  attention  of 
the  observer. 

The  numerical  units  with  which  we  are  cencerned  in  vital  statis- 
tics are  persons,  either  living  or  dead,  and  these  are  divided  into 
groups,  according  to  age,  sex,  race,  etc.  Populations  tend  naturally 
to  increase,  the  natural  increment  being  measured  by  the  difference 
in  the  number  of  births  and  deaths ;  but  the  actual  increment  depends 
upon  how  this  is  modified  by  the  relation  between  immigration  and 
emigration.  If  these  factors  were  all  constant,  the  population  would 
increase  in  geometrical  progression;  but  as  this  is  not  so  it  cannot 
be  exactly  determined  for  periods  other  than  those  in  which  the  cen- 
sus is  taken.  However,  in  determining  the  population  for  years 
other  than  census  years,  it  is  customary  to  assume  that  the  same  rate 
of  increase  continues  as  prevailed  between  the  last  two  censuses,  and 
to  calculate  the  population  therefrom  by  means  of  geometrical  pro- 
gressions or  logarithms.  The  number  of  houses  in  a  city  will  help 
to  determine  the  approximate  population,  for  the  average  number  of 
persons  to  the  house  in  any  city  remains  about  the  same  from  year 
to  year.  Such  counts,  as  well  as  police  censuses,  are,  however,  almost 
always  too  high.  In  small  and  slowly-growing  districts  one-tenth  of 
the  difference  in  population  of  the  last  two  censuses  may  be  taken  for 
each  year  since  the  last  census.  The  population  is  always  counted 
and  annual  birth-  and  ^eath-  rates  calculated  in  this  country  for  the 
middle  of  the  year. 

REGISTRATION  OF  BIRTHS. 

The  collection  of  data  for  an  accurate  registration  of  births  is 
much  more  difficult  than  the  record  of  deaths.  Instead  of  requiring 
physicians  and  midwives  in  attendance  at  the  confinement  to  report 
births,  it  would  be  more  equitable  and  probably  more  effectual  to  com- 
pel the  parents,  under  penalty  for  failure,  to  record  the  birth  of 
each  child  at  the  board  of  health.  The  items  usually  included  in 
birth  returns  are:  date  and  place  of  birth,  sex  and  color  of  child, 
names  of  father  and  mother,  parents'  nativity  and  age,  and  father's 


Registration  of  diseases.  465 

occupation.  Sometimes  the  residence  of  the  mother,  number  of  chil- 
dren previously  borne  by  the  same  mother,  whether  the  child  is 
legitiniate  or  not,  and  various  other  details  are  also  added.  It  is  evi- 
dent that  for  sanitary  purposes  most  of'  this  information  is  entirely 
irrelevant.  It  seems  to  the  author  that,  for  the  purpose  of  the  sani- 
tarian and  medical  statistician,  the  date  and  p^ace  of  birth,  sex  and 
color  01  the  child,  and  age,  nativity,  and  occupation  of  both  parents 
are  sufficient. 

REGISTRATION  OF  MARRIAGES. 

The  record  of  marriages  is  of  no  interest  to  the  sanitarian.  If, 
however,  the  registration  could  be  made  by  a  competent  medical  man, 
and  the  physical  condition  of  the  contracting  parties  noted,  valuable 
deductions  might  be  made  in  time,  especially  if  the  parties  themselves 
and  their  offspring  could  be  kept  under  observation  for  many  years. 
This,  however,  is  so  manifestly  impracticable  that  it  barely  deserves 
notice  in  this  place. 

REGISTRATION  OF  DISEASES. 

As  has  been  seen  in  Chapter  XIX,  a  large  class  of  diseases  are 
communicable  from  one  individual  to  another,  either  directly,  by 
contact,  or  mediately,  by  infection.  In  large  communities  it  is  there- 
fore important  that  the  sanitary  authorities  should  possess  informa- 
tion of  the  presence  and  prevalence  of  these  diseases,  in  order  that 
measures  may  be  instituted  for  their  restriction.  It  is  true  that  in 
most  cases  the  registration  of  deaths  gives  but  too  mournful  evidence 
of  the  more  fatal  of  the  diseases  of  this  class,  but  destructive  epi- 
demics could  probably  be  frequently  averted  if  preventive  measures 
could  be  enforced  early.  Besides,  in  the  case  of  dengue  and  epidemic 
influenza  the  death-rate  may  be  so  small  that,  if  the  registration  of 
deaths  were  alone  depended  upon,  no  evidence  whatever  might  be 
attainable  of  the  epidemic  prevalence  of  such  diseases. 

The  registration  of  prevailing  diseases  is,  therefore,  one  of  the 
most  important  duties  of  the  registrar  of  vital  statistics.  Prompt 
notices  of  all  cases  of  infectious,  miasmatic,  or  contagious  diseases 
coming  under  their  professional  notice  should  be  required  of  all 
physicians.  It  is  unquestionably  just,  however,  that  the  physicians 
required  to  perform  this  duty  should  be  properly  compensated  by  the 
public,  whose  interests  they  serve. 

30 


466  TEXT-BOOK  OF  HYGIENE. 

REGISTRATION  OF  DEATHS. 

The  data  entered  upon  the  record  of  death  should  comprise  the 
name,  age,  sex,  color,  nativity,  descent,  occupation,  and  civil  con- 
dition of  decedent,  with  date,  place,  and  cause  of  death.  Under,  the 
heading  "Descent"  the  birthplace  of  each  parent  should  be  given. 
Occupation  should  be  accurately  specified.  The  place  of  death  should 
indicate  the  exact  locality  (number  of  street)  where  it  occurred. 
Both  proximate  and  predisposing  causes  of  death  should  be  entered, 
and  any  complications  which  may  have  influenced  the  fatal  termina- 
tion should  be  noted  on  the  record. 

The  record  should  be  in  the  possession  of  the  local  health  author- 
ity before  a  permit  for  the  burial  of  the  deceased  is  granted.  If  this 
is  not  insisted  upon,  the  report  will  soon  be  omitted  and  the  registra- 
tion become  defective.  In  fact,  any  system  that  puts  off  the  collecting 
and  recording  of  the  death  returns  until  the  end  of  the  year  will 
fail  to  register  from  25  to  40  per  cent,  of  the  number. 

DEATH=RATE  AND  BIRTH=RATE. 

In  order  to  calculate  the  annual-  death-rate  of  a  place  two  facts 
are  required  to  be  known :  first,  the  acutal  or  estimated  population 
(generally  obtained,  as  indicated,  from  the  census),  and,  second,  the 
number  of  persons  who  died  in  the  district  during  the  year.  The 
number  of  deaths  is  divided  by  the  population,  which  gives  the  death- 
rate  for  each  individual  for  the  year.  To  find  the  death-rate  per 
1000  the  rate  as  found  above  is  multiplied  by  1000.  Thus,  the  total 
number  of  deaths  in  the  city  of  Philadelphia  during  1893  was  23,- 
655,  and  the  estimated  population  1,115,562.  The  death-rate  for 
the  year  was  21,20  per  1000,  obtained  as  follows: — 

23.655  X  1000 

— '- =  21.20  per  M. 

1,115,562 

To  calculate  the  annual  death-rate  per  1000  of  a  place  from  the 
returns  for  one  week,  the  weekly  population  is  first  ascertained  and 
then  the  number  of  deaths  for  the  week  divided  by  the  weekly  popu- 
lation and  the  quotient  multiplied  by  1000.  The  following  example 
will  render  this  clear : — 

The  exact  number  of  weeks  in  a  year  is  52.17747.  The  total 
population  is  divided  by  this  number,  giving  the  weekly  popiilation. 
This  gives  for  Philadelphia,  assuming  the  above  estimate  to  be  correct, 
a  weekly  population  of  21,381.     For  the  week  ending  June  3,  1893, 


DEATH-RATE  AND  BIRTH-RATE.  467 

the  deaths  in  that  city  numbered  388.  The  annual  death-rate  per 
1000 — that  is  to  say,  the  number  of  deaths  in  each  1000  of  popula- 
tion, if  the  same  rate  be  maintained  throughout  the  year — is  ob- 
tained as  follows: — 

388  X  1000 

=18.15  per  M. 

21,381 

The  daily  death-rate  is  obtained  in  a  similar  manner,  the  divisor 
for  obtaining  the  daily  population  being  365,  24226,  and  the  monthly 
population  is  found  by  multiplying  the  daily  population  by  the  num- 
ber of  days  in  the  respective  months.  But  it  should  be  remembered 
that  these  rates  for  such  short  periods  cannot  by  any  means  accurately 
indicate  the  actual  annual  rate,  and  that  they  are  to  be  used  only  for 
comparing  the  rates  for  similar  periods  at  different  seasons,  etc. ; 
otherwise,  with  such  large  populations  and  such  short  periods  the 
probabilities  of  error  are  too  great  for  the  results  to  be  of  any  value. 

The  annual  zymotic  or  infectious  death-rate,  or  that  for  any  one 
disease,  is  obtained  in  the  same  manner  as  the  general  annual  death- 
rate,  and  likewise  the  birth-rate.  Or,  to  find  the  annual  death-rate  per 
1000  of  population  for  this  class  of  diseases,  the  following  calculation 
may  be  made.  Thus,  out  of  the  above  388  deaths,  84  were  from  in- 
fectious diseases: — 

84  X  1000 

=3.93  per  M.  per  annum. 

21,381 

Or,  if  the  percentage  of  deaths  from  infectious  diseases  be  de- 
sired, the  procedure  would  be  as  follows : — 

84  X  100 

=  21.65  per  cent,  of  the  total  deaths. 

388 

As  an  exception  to  the  rule,  the  rate  of  infant  mortality  or  in- 
fantile death-rate  is  indicated  by  the  ratio  of  deaths  of  children  under 
one  year  to  the  number  of  births  recorded  for  the  year,  and  is  found 
by  multiplying  the  number  of  infantile  deaths  by  1000  and  dividing 
by  the  number  of  births;  for  example,  for  the  year  just  quoted  the 
decedents  under  one  year  of  age  numbered  5710;  the  total  number 
of  births  for  the  same  year  was  30,737.  Hence — 
5710  X  1000 
^I^ =  185.77  per  1000  births. 

Nineteen  of  the  388  deaths  for  the  week  ending  June  3,  were 
of  colored  persons.  The  death-rate  of  these  to  the  total  population  is 
found  in  a  similar  manner  to  the  above;   but  if  it  is  desired  to  asccr- 


468  TEXT-BOOK  OF  HYGIENE. 

tain  the  death-rate  of  the  colored  population  alone,  the  v.^eekly  colored 
population  must  first  be  obtained,  and  the  rate  calculated  from  this 
by  the  above  formula. 

There  are  a  number  of  factors  that  affect  the  general  death-rate, 
such  as  the  size  of  the  community,  habits  of  life,  age-  and  sex-  dis- 
tribution, occupation  of  the  bulk  of  the  inhabitants,  etc.  For  the 
country  and  small  towns  the  rate  should  be  from  9  to  16  per  1000, 
gradually  increasing  until  for  the  largest  cities  it  amounts  to  from 
18  to  21  per  1000.  Death-rates  reported  below  these  figures  would 
indicate  that  all  the  deaths  had  not  been  recorded,  or  that  the  popula- 
tion had  been  overestimated;  rates  above  would  be  evidence  that 
there  vrere  special  causes  at  work  demanding  sanitary  investigation 
and  improvement. 

Among  the  causes  that  make  the  mortality  among  infants  and 
children  high  are  parents  too  young  or  sickly,  hereditary  taints,  un- 
healthy environments,  improper  and  insufficient  food  and  clothing, 
and,  not  rarely,  infant  life-insurance.  It  is  simply  the  manifestation 
of  one  of  the  workings  of  the  law  of  "the  survival  of  the  fittest." 
In  localities  newly  settled,  where  the  proportion  of  adults  to  children 
is  greater  than  the  normal,  the  death-rate  is  naturally  lower ;  though 
it  is  conceivable  that  the  occupations  in  which  the  adults  engaged  and 
the  vicissitudes  and  unsettled  conditions,  both  sanitary  and  social,  of 
a  new  settlement  might  cause  or  tend  to  cause  a  very  high  mortality. 
Since  more  males  die  than  females,  the  sex-distribution  will  also 
have  its  influence  on  the  death-rate,  especially  if  there  is  a  prepon- 
derance of  one  sex  over  the  other  in  any  locality. 

Many  conditions  affect  the  death-rate  from  the  different  diseases, 
namely,  age,  race,  sex,  occupation,  environment,  seasons,  temperature, 
etc.  The  zymotic  death-rate,  and  especially  that  part  of  it  due  to 
typhoid  fever,  may  be  an  extremely  good  index  of  the  actual  value  and 
benefit  of  sanitary  improvements  and  the  enforcement  of  hygienic 
lav/s.  Thus,  the  mortality  from  typhoid  fever  in  England  and  Wales 
has  been  reduced  more  than  50  per  cent,  since  the  introduction  and 
enforcement  of  the  general  sanitary  regulations  in  that  kingdom. 

On  account  of  lack  of  registration  of  all  cases  of  disease,  it  is 
practically  impossible  to  determine  the  sick-rate  of  a  community  or 
population;  but  it  is  said  that  the  sickness  of  a  community  amounts 
to  the  disablement  of  one  person  for  two  years  for  every  death,  and 
the  records  of  English  beneficial  societies  seem  to  show  that  each 
member  averages  about  one  and  one-half  weeks'  sickness  annually. 

The  following  definitions  are  introduced  because  the  terms  are 


DEATH-RATE  AJND  BIRTH-RATE.  469 

frequently  used  in  discussions  of  vital  statistics,  and  especially  of  life- 
insurance.  The  comparative  mortality  figure  indicates  that  the 
same  number  of  persons  that  gave  1000  deaths  in  the  whole  population 
would  furnish  the  deaths  indicated  by  the  figure  in  the  city  or  locality 
in  question.  Thus,  if  the  comparative  mortality  figure  of  a  place 
is  925  and  the  death-rate  of  the  country  is  20,  there  are  1000  deaths 
for  every  50,000  of  the  whole  population  and  the  death-rate  of  the 
given  place  is  18.5.     For  20 :  1000 :  :  a; :  925  and  x  =  18.5. 

The  average  or  mean  age  at  death  is  ascertained  by  adding  up  the 
ages  of  all  the  decedents  and  dividing  the  sum  by  the  number  of 
deaths.  Unless  it  is  derived  from  the  life-tables  of  an  entire  gen- 
eration, it  is  not  a  fair  index  of  longevity  or  of  sanitary  conditions, 
since  it  is  affected  considerably  by  the  age-distribution  of  the  popula- 
tion from  which  it  is  compiled. 

The  expectation  of  life  at  any  age  is  the  average  number  of  years 
which  persons  of  that  age  may  expect  to  live.  For  the  newborn  it  is 
the  same  as  the  mean  duration  of  life,  and,  "as  applied  to  commu- 
nities, it  is  the  mean  life-time  of  a  generation  of  persons  traced  by  the 
life-table  method  from  birth  to  death,  and  is  the  only  true  test  of  the 
health  of  populations."  A  life-table  is  computed  from  the  number 
and  ages  of  the  living  and  of  those  that  die,  these  factors  being  ob- 
tained from  the  average  population  for  each  age  and  sex,  and  from 
the  total  death-returns  between  two  or  more  censuses.  It  is,  as  Dr. 
Farr  says,  "a  barometer  which  indicates  the  exact  measure  of  the 
duration  of  life  under  given  circumstances,  and  is  indispensable  in 
gauging  the  influence  of  sanitary  or  insanitary  conditions." 

It  is  only  when  the  population  does  not  vary  as  to  age-  or  sex- 
distribution  that  the  mean  duration  of  life  is  identical  with  the  aver- 
age age  at  death.  Otherwise,  for  any  person  at  any  age  it  is  the  same 
as  the  expectation  of  life.  The  probable  duration  of  life  is  equivalent 
to  the  age  at  which  any  number  of  newborn  children  will  be  reduced 
one-half,  the  same  conditions  persisting.  With  a  million  children  as 
a  basis,  it  is  less  than  forty-five  years  for  males  and  about  forty-seven 
years  for  females. 

It  will  be  evident,  on  a  little  thought,  that  there  must  be  many 
sources  of  error  in  calculations  based  upon  such  uncertain  data  as 
are  derived  from  the  registration  of  births  and  deaths  as  conducted 
in  most  cities  in  this  country.  Besides,  the  subject  of  vital  statistics 
is  essentially  abstruse,  and  requires  no  little  readiness  in  mathematics 
to  appreciate  its  profounrlor  bearings.  Hence,  in  the  foregoing 
chapter,  no  attempt  has  been  made  to  penetrate  beyond  the  imme- 
diate practical  aspects  of  the  questions  involved. 


QUESTIONS  TO  CHAPTER  XIX. 

VITAL  STATISTICS. 

What  is  comprised  in  the  registration  of  vital  statistics?  How  are  they 
to  be  made  of  use?  Of  what  value  are  the  recorded  statistics  to  the  sanitarian? 
How  else  may  disease  be  studied?  Why  may  not  the  same  methods  of  deter- 
mining the  general  health  be  applied  to  large  communities  as  to  small  ones? 

What  is  the  census?  What  returns  of  interest  to  the  sanitarian  does 
it  make?  Which  of  these  are  the  most  important?  Why?  What  is  the 
advantage  of  furnishing  returns  for  "sanitary  districts,"  and  what  is  meant 
by  the  latter? 

What  returns  are  to  be  obtained  from  the  registration  bureau?  Who 
furnishes  these  returns?  Who  should  have  charge  of  the  registration?  Why? 
Why  should  physicians  make  the  returns?  Why  should  the  State  take  care 
in  the  licensing  of  physicians  to  practice?  What  is  the  most  important  object 
of  the  registration  of  vital  statistics  ? 

What  are  the  fundamental  principles  underlying  all  statistical  inquiry? 
What  units  or  cases  should  be  omitted?  What  renders  the  classification  of 
groups  difficult?  What  is  the  usual  standard  of  comparison?  When  is  the 
relation  of  component  groups  to  the  total  constant?  How  may  the  probable 
limit  of  variation  be  determined?  What  tends  to  make  the  arithmetical  mean 
approach  the  invariable?  How  may  the  relative  value  of  different  series  of 
the  same  kind  of  cases  be  determined?  What  is  the  difference  between  aver- 
ages and  extreme  values  ?  Of  what  value  is  the  graphic  method  of  representing 
statistical  results  ? 

What  are  the  units  of  vital  statistics?  How  may  they  be  divided  into 
groups?  What  is  the  natural  increment  of  a  population?  How  does  this 
differ  from  the  actual  increment?  If  the  factors  were  constant,  how  would 
a  population  increase?  Why?  Why  cannot  the  population  be  determined 
exactly  for  intercensal  periods?  What  is  the  usual  and  most  accurate  way 
of  determining  it?  How  else  may  it  be  estimated?  What  is  the  fault  of 
counts  made  by  local  authorities  or  police  censuses?  At  what  time  of  the 
year  is  the  count  always  made?  For  what  time  are  annual  death-rates,  etc., 
calculated? 

Why  is  the  collection  of  data  for  birth-records  difficult?  Who  should 
make  the  return?  What  items  are  usually  included  in  the  returns?  Which 
are  the  only  ones  of  value  to  the  sanitarian  and  medical  statistician?  Why 
is  the  record  of  marriages  of  no  sanitary  interest?  How  might  it  be  made 
so?     Is  this  practicable? 

^^Tiat  classes  of  diseases  should  be  reported  and  recorded?  Why?  ^Vllat 
epidemic  diseases  might  escape  notice  by  the  statistician  if  only  reported  in 
death-returns?  When  should  the  returns  of  infectious  diseases  be  made? 
Should  there  be  any  recompense  for  the  returns  to  the  physicians? 

(470) 


QUESTIONS  TO   CHAPTER   XIX.  471 

What  data  should  be  given  by  a  death-certificate?  Which  items  should 
be  accurately  specified?  What  care  should  be  taken  in  reporting  the  cause 
of  death?     When  should  the  burial-permit  be  issued? 

What  factors  are  required  in  order  to  calculate  the  death-rate  of  a 
locality?  How  is  the  death-rate  for  the  year  obtained?  How  may  the  annual 
death-rate  of  a  place  be  calculated  from  the  death-returns  for  one  week  ?  What 
is  the  weekly  and  the  daily  population?  How  is  the  monthly  population 
found?  What  is  the  objection  to  rates  determined  from  returns  for  such 
short  periods?     Of  what  value  are  they? 

What  is  meant  by  the  zymotic  or  infectious  death-rate?  How  may  it 
be  determined?  How  is  the  percentage  of  deaths  due  to  infectious  disease 
determined?     How  is  the  rate  of  infant  mortality  determined? 

What  factors  aflfect  the  general  death-rate  ?  What  is  a  fair  death-rate 
for  small  communities?  For  large' cities?  What  do  higher  rates  than  this 
usually  indicate?  What  do  lower  ones?  What  causes  make  the  mortality  so 
high  among  infants  and  young  children.  What  may  make  the  death-rate  of 
a  community  lower  than  the  normal?  What  higher?  How  may  sex-distribu- 
tion affect  the  death-rate?  What  conditions  or  factors  affect  the  mortality 
from  the  different  diseases?  How  may  the  zymotic  death-rate  be  an  index  of 
the  value  of  sanitary  measures? 

Why  is  it  so  difficult  to  determine  the  sick-rate  of  a  community?  How 
may  the  total  amount  of  sickness  be  approximately  estimated? 

What  is  meant  by  the  comparative  mortality  figure  ?  What  by  the  aver- 
age age  at  death  ?  Is  this  necessarily  a  fair  index  of  longevity  ?  What  affects 
it?  What  is  meant  by  the  expectation  of  life?  Of  what  value  is  it  when 
applied  to  communities?  What  is  a  life-table,  and  how  is  it  computed?  Of 
what  value  is  it  to  sanitarians?  When  is  the  mean  duration  of  life  identical 
with  the  average  age  of  death  ?  What  is  meant  by  the  probable  duration  of 
life?  Why  are  calculations  of  vital  statistics  liable  to  be  unreliable  or  in- 
accurate ? 


CHAPTER  XX. 

QUARANTINE. 

By  quarantine  is  meant  the  adoption  of  restrictive  measures  to 
prevent  the  introduction  of  diseases  from  one  country  or  locality  into 
another.  The  term  itself  conveys  no  definite  idea,  being  derived 
through  the  Italian  from  the  Latin  "quadraginta/'  meaning  "forty" 
and  implying  forty  days — the  period  of  detention  imposed  on  vessels 
by  the  first  quarantines  established  at  Venice  in  1403.  The  old  sig- 
nificance of  the  term  is  entirely  lost  in  its  present  application,  which 
is  quite  general.  Thus,  besides  regular  maritime  quarantine,  mention 
is  often  made  of  land,  railroad,  cattle,  shot-gun,  house,  and  even  room 
quarantine. 

The  name  of  a  disease  or  article  of  merchandise  may  be  used 
in  a  prefix,  as  in  "yellow-fever  quarantine,"  small-pox,  cholera,  or 
rag  quarantine.  Moreover,  quarantines  are  described  as  properly  be- 
ginning at  the  port  of  departure,  and  as  quarantine  of  inspection 
only,  the  fumigation  and  detention  being  imposed  at  some  neighboring 
station.  The  term,  therefore,  is  applied  not  only  to  establishments, 
but  indifferently  to  persons,  animals,  diseases,  localities,  and  measures. 

There  is  need  of  a  clear  understanding  with  regard  to  the  term, 
for  when,  as  occasionally,  quarantine  is  ridiculed,  or  the  assertion 
is  made  that  the  English  disbelieve  in  quarantine,  a  wrong  impression 
Avill  be  received,  unless  it  is  understood  that  only  particular  and 
obsolete  forms  of  quarantine  are  meant,  and  not  quarantine  in  the 
broad  sense  Just  mentioned. 

The  subject  admits  of  two  natural  divisions — maritime  and  land 
quarantine;  but  before  describing  them  attention  is  called  to  the 
following  table,  containing  a  list  of  diseases  that  are  ordinarily 
found  in  official  quarantine  proclamations: — 

This  list  illustrates  the  growth  of  the  sanitary  idea  and  belief 
in  quarantine.  For  many  years,  as  now  at  some  ports,  the  list  was 
limited  to  yellow  fever,  typhus,  cholera,  and  small-pox.  It  was  thus 
limited  at  Boston  prior  to  1881,  since  which  date  diphtheria,  scarlet 
fever,  typhoid  fever,  and  measles  have  been  added.  The  statutes  of 
New  York  define  as  quarantinable  "yellow  fever,  measles,  cholera, 
typhus  or  ship  fever,  small-pox,  scarlatina,  diphtheria,  relapsing  fever, 
and  any  disease  of  a  contagious,  infectious,  or  pestilential  character 
(472) 


FOREIGN  QUARANTINE. 


473 


Table  LIX. 
Quarantinable  Diseases. 


Disease 


Plague 

Yellow  fever  . . 

Cholera 

Tj'phus  fever. . 

Small-pox 

Measles 

Diphtheria  . . . 
Typhoid  fever. 
Scarlet  fever  . . 
Relapsing  fever 

Dengue 

Leprosy 


Period  of  Incubation,  in  days 


Shortest     Longest         Usual         Authority  and  Remarks 


14 

21 
20 
14 
10 

28 

Weeks 

7 

10 


3  to  5 

oi 

-ij 

2   to  "-4 
5  to  14 

10 

10 
2  to  5 

21 

4  to  7 
6 

5 


Kitasato. 

Da  Costa,  Bartholow, 

Reed,  Caiver. 
Bartholow. 
Br  i  stow. 
Da  Costa. 
Da  Costa. 
Bartholow. 
Bartholow. 
Da  Costa. 
Bartholow. 
Barthiilow. 
Undetermined. 


which  shall  be  considered  by  the  health  officer  dangerous  to  the 
public  health." 

At  Gibraltar,  the  English  sanitary  authorities  include  dengue 
and  epidemic  rose-rash  among  the  diseases  subject  to  their  quarantine 
regulations. 

Another  addition  to  the  list  in  this  country  is  leprosy,  to  prevent 
the  introduction  of  which,  and  in  accordance  with  a  resolution  of  the 
American  Public  Health  Association,  a  prohibitory  circular  was  issued 
by  the  Surgeon-General  of  the  Marine-Hospital  Service,  December 
23,  1889. 

Other  diseases  which  may  properly  call  for  quarantine  are  mumps, 
whooping  cough,  chicken-pox,  epidemic  dysentery,  glanders,  tetanus, 
beriberi,  epidemic  influenza,  and  pulmonary  tuberculosis. 

Influenza  may  be  considered  quarantinable  under  certain  circum- 
stances, a  successful  quarantine  being  reported  by  Dr.  Trudeau,  whose 
cottage  sanitarium,  in  the  Adirondacks,  New  York,  was  thus  kept 
exempt  during  the  epidemic  of  1890. 

With  regard  to  pulmonary  tuberculosis  the  ground  is  taken  by 
the  writer  that  this  disease,  at  least  among  immigrants,  should  be 
excluded  from  the  United  States  by  quarantine. 


FOREIGN  QUARANTINE. 

The  object  of  maritime  quarantine  being  protection  against  the 
importation  of  contagious  or  infectious  disease,  chiefly  from  abroad, 


474  TEXT-BOOK  OF  HYGIENE. 

through  the  medium  of  vessels,  their  crews,  passengers,  and  cargoes, 
it  is  most  logical  that  restrictive  measures  should  begin  at  the  port 
of  departure.  Following  are  the  regulations  prepared  by  the  Surgeon- 
General  of  the  Public  Health  and  Marine-Hospital  Service  of  the 
United  States  and  promulgated  by  the  Secretary  of  the  Treasury, 
April  1,  1903.  All  quarantine  regulations  are  subject  to  occasional 
revision  under  the  Act  of  Congress  approved  February  15,  1893. 

QUARANTINE   REGULATIONS. 

QUAEANTINABLE    DISEASES. 

1.  For  the  purpose  of  these  regulations  the  quarantinable  dis- 
eases are  cholera,  yellow  fever,  small-pox,  typhus  fever,  leprosy,  and 
plague. ' 

Foreign  Eegulations. 

Quarantine  Regulations  to  be  Observed  at  Foreign  Ports  and  at 
Poets  in  the  Possessions  andDependencies  of  the  United  States. 

Bills  of  Health. 

2.  Masters  of  vessels  departing  from  any  foreign  port,  or  from 
any  port  in  the  possessions  or  other  dependencies  of  the  United 
States  for  a  port  in  the  United  States  or  its  possessions  or  other  de- 
pendencies, must  obtain  a  bill  of  health,  in  duplicate,  signed  by  the 
proper  officer  or  officers  of  the  United  States  as  provided  for  by  law, 
except  as  provided  for  in  paragraph  4. 

The  following  form  is  prescribed: — 

Form  No.  1937. 
United  States  Bill  of  Health. 

Name  of  vessel, .    Nationality, .    Rig, .    Master, . 

Tonnage,  gross, ;    net, .    Iron  or  wood.    Number  of  compartments 

for  cargo, ;    for  steerage  passengers,  ;    for  crew,  . 

Name  of  medical  officer,  . 

Number  of  officers,  . 

Number  of  members  of  officers'  families,  . 

Number  of  crew,  including  petty  officers,  . 

Number  of  passengers,  cabin,  . 

Number  of  passengers,  steerage,  . 


Number  of  persons  on  board,  all  told,  . 

Port  of  departure,  . 

Where  last  from,  . 

Number  of  cases  of  sickness  and  character,  during  last  voyage. 


FOREIGN  QUARANTINE.  475 

Vessel  engaged  in  trade,  and  plies  between  and  ■ — . 

Sanitary  condition  of  vessel, . 

Nature,  sanitary  history,  and  condition  of  cargo,  , 

Source  and  wholesomeness  of  water  supply,  . 

Source  and  wholesomeness  of  food  supply,  . 

Sanitary  history  and  health  of  officers  and  crew,  . 

Sanitary'  history  and  health  of  passengers,  cabin,  . 

Sanitary  history  and  health  of  passengers,  steerage,  . 

Sanitary  history  and  condition  of  their  effects,  . 

Prevailing   diseases   at   port  and  vicinity,   . 

Location  of  vessel  while  discharging  and  loading— open  bay  or  wharf,  . 

Number  of  cases  and  deaths  from  the  following-named  diseases  during  the 
past  two  weeks: 

Yellow   fever    — — 

Asiatic  cholera    

Cholera  nostras  or  cholerine 

Small-pox    

Typhus  fever   

Plague  

Leprosy   

Number  of  cases  of  sickness  and  character  of  same  while  vessel  was  in  this 
port, — . 

Any  conditions  affecting  the  pviblie  health  existing  in  the  port  of  departure 

or  vicinity  to  be  here  stated,  . 

I  certify  that  the  vessel  has  complied  with  the  rules  and  regulations  made 
under  the  act  of  February  15,  1893,  and  that  the  vessel  leaves  this  port  bound 
for ,  U.  S.  of  America,  via  . 

Given  under  my  hand  and  seal  this  day  of  ,  190     . 

( Signature  of  consular  officer : ) , 


3.  Vessels  clearing  from  a  foreign  port  or  from  any  port  in  the 
possessions  or  other  dependencies  of  the  United  States  for  any  port  in 
the  United  States,  its  possessions  or  other  dependencies,  and  entering 
or  calling  at  intermediate  ports,  must  procure  at  all  said  ports  a  sup- 
plemental hill  of  health  in  duplicate  signed  by  the  proper  officer  or 
officers  of  the  United  States,  as  provided  in  the  law.  If  a  quarantin- 
able  disease  has  appeared  on  board  the  vessel  after  leaving  the  original 
port  of  departure,  or  other  circumstances  presumably  render  the  ves- 
sel infected,  the  supplemental  bill  of  health  should  be  withheld  until 
such  sanitary  measures  have  been  taken  as  are  necessary. 

The  following  form  is  prescribed  : — 

Supplemental  Bill  of  Health. 

Port  of . 

Vessel  ,  bound  from  to  ,  U.  S.  A. 

Sanitary  condition  of  port,  . 


476 


TEXT-BOOK  OF  HYGIENE. 


State  diseases  prevailing  at  port  and  in  surrounding  country,  . 

Number  of  cases  and  the  deaths  from  the  following-named  diseases  during 
the  past  two  weeks:  — 

Table  LX. 
Table  of  Diseases. 


Diseases 


No.  of 
Cases 


No.  of 
deaths 


Remarks 

(Any  condition  affecting  the  public  health  existing 

in  the  port  to  be  stated  here.) 


Yellow  fever 

Asiatic  cholera  . .  . . 
Cholera  nostras,  or 

cholerine 

Small-pox 

Typhus  fever 

Plague  

Leprosy 


Number  and  sanitary  condition  of  passengers  and  crew  landed  at  this  port. 

Cabin,  No.  .     Sanitary  condition  and  history,  . 

Steerage,  No.  .     Sanitary  condition  and  history,  . 

Crew,  No.  .     Sanitary  condition  and  history,  . 

Note. — If  disembarked  on  account  of  sickness  state  disease,  . 


Number  and  sanitary  condition  of  passengers  and  crew  taken  on  at  this  port, 
and  sanitary  condition  of  effects. 

Cabin,  No.  .     Sanitary  condition  and  history,  . 

Steerage,  No.  .     Sanitary  condition  and  history,  . 

Crew,  No.  .     Sanitary  condit'on  and  history,  . 

Sanitary  condition  of  effects,  . 

Sanitary  history  of  vessel  since  leaving  last  j)ort. 
(Cancel  Form  A,  B,  or  C,  as  the  case  requires.) 


Form. 


A. — To  the  best  of  my  knowledge  and  belief —    ] 


I   no  quarantinable  disease  has 
f       appeared  aboard  since  leav- 


(Form  A  will  be  used  at  intermediate  ports  where 
the  vessel  dues  not  enter  and  clear.) 

B. — I  have  satisfied  myself  that — 

(Form  B  will  be  used  at  intermediate  porls  where    J 
the  vessel  enters  and  clt  ars. ) 

C. — Since    leaving   the    following   quarantinable    disease    has    appeared 

on  board  ,   and   I   certify  that  the  necessary   sanitary  measures   have 

been  taken. 

I  certify  also  that  with  reference  to  the  passengers,  effects,  and  cargo  taken 
on  at  this  port,  the  vessel  has  complied  with  the  rules  and  regulations  made 
under  the  act  of  February  15,   1893. 

Given  tmcer  my  hand  and  seal  this  day  of  ,   190     . 

( Signature  of  consular  officer : ) , 


FOREIGN  QUARANTINE.  477 

4.  Under  the  act  of  Congress  approved  August  18,  1894,  vessels 
pl3dng  between  Canadian  ports  on  the  St.  Croix  Eiver,  the  St.  Law- 
rence Eiver,  the  Niagara  River,  the  Detroit  Eiver,  the  St.  Clair  Eiver, 
and  the  St.  Mary's  Eiver,  and  adjacent  ports  of  the  United  States  on 
the  same  waters;  also  vessels  plying  between  Canadian  ports  on  the 
following-named  lakes,  viz,,  Ontario,  Erie,  St.  Clair,  Huron,  Superior, 
Eainy  Lake,  Lake  of  the  Woods,  and  Lake  Champlain,  and  ports  in 
the  United  States;  also  vessels  plying  between  Mexican  ports  on  the 
Eio  Grande  Eiver  and  adjacent  ports  in  the  United  States,  are  exempt 
from  the  provisions  of  section  2  of  the  act  granting  additional  quar- 
antine powers  and  imposing  additional  duties  upon  the  Marine-Hos- 
pital Service,  approved  February  15,  1893,  which  requires  vessels 
clearing  from  a  foreign  port  for  a  port  in  the  United  States  to  obtain 
from  the  consular  or  medical  officer  a  bill  of  health.  During  the 
prevalence  of  any  of  the  quarantinable  diseases  at  the  foreign  port  of 
departure,  vessels  above  referred  to  are  hereby  required  to  obtain 
from  the  consular  officer  of  the  United  States,  or  from  the  medical 
officer  of  the  United  States,  when  such  officer  has  been  detailed  by  the 
President  for  this  purpose,  a  bill  of  health,  or  a  supplemental  bill 
of  health,  in  duplicate,  in  the  form  prescribed  by  the  Secretary  of  the 
Treasury. 

Inspection  of  Vessels  Leaving  Foreign  Ports  and  Ports  in  tire  Pos- 
sessions or  other  Dependencies  of  the  United  States  for  Ports  in 
the  United  States  or  its  Possessions  or  other  Dependencies. 

5.  The  officer  issuing  the  bill  of  health  shall  satisfy  himself,  by 
inspection,  if  necessary,  that  the  conditions  certified  to  therein  are 
true,  and  is  authorized,  in  accordance  with  the  law,  to  withhold  the 
bill  of  health  or  the  supplemental  bill  of  health  until  he  is  satisfied 
that  the  vessel,  the  passengers,  the  crew,  and  the  cargo  have  complied 
with  all  the  quarantine  laws  and  regulations  of  the  United  States. 

6.  Inspection  is  required  of — 

(a)  All  vessels  from  ports  at  which  cholera,  3^ellow  fever,  or 
plague  prevails,  or  at  which  small-pox  or  typhus  fever  prevails  in 
epidemic  form. 

(h)  All  vessels  carrying  steerage  passengers;  but  need  only  in- 
clude the  inspection  of  such  passengers  and  their  living  apartments, 
if  sailing  from  a  healthy  port. 

7.  Inspection  of  the  vessel  is  such  an  examination  of  the  vessel, 
cargo,  passengers,  ei-ew,  personal  cff'ects  of  same,  including  examina- 
tion of  manifests  and  other  papers,  food-  and  water-  supply,  the  as- 


478  TEXT-BOOK  OF  EYGTENE. 

certainment  of  its  relations  Avith  the  shore,  the  manner  of  loading,  and 
possibilities  of  invasion  by  small  animals  as  will  enable  the  inspecting 
officer  to  determine  if  these  regulations  have  been  complied  with. 

8.  When  an  inspection  is  required,  it  should  be  made  by  daylight, 
as  late  as  practicable  before  sailing.  The  vessel  should  be  inspected 
before  the  j)assengers  go  aboard,  the  passengers  just  before  embarka- 
tion, and  the  crew  on  deck;  and  no  communication  should  be  had 
with  the  vessel  after  such  inspection  except  by  permission  of  the  officer 
issuing  the  bill  of  health. 

Requirements  ivilh  Regard  to  Vessels. 

9.  Vessels,  prior  to  stowing  cargo  or  receiving  passengers,  should 
be  mechanically  clean  in  all  parts,  especially  the  hold,  forecastle,  and 
steerage ;  the  bilges  and  limbers  free  from  odor  and  deposit.  The  air 
streaks  should  be  sufficient  in  number  and  open  for  ventilation. 

10.  Any  portions  of  the  vessel  liable  to  have  been  infected  by  any 
communicable  disease  should  be  disinfected  before  the  issuance  of  the 
bill  of  health. 

11.  The  air-space,  ventilation,  food-  and  water-  supply,  hospital 
accommodations,  and  all  other  matters  mentioned  therein  promotive 
of  the  health  and  comfort  of  the  passengers  must  be  in  accordance 
with  the  provisions  of  the  act  of  Congress  approved  August  2,  1882, 
entitled  "An  act  to  regulate  the  carriage  of  passengers  by  sea." 

12.  At  ports  Avhere  cholera  prevails  in  epidemic  form,  special  care 
should  be  taken  to  prevent  the  water-  and  the  food-  supply  from 
being  infected.  The  drinking-water  should  be  boiled  and  the  food 
thoroughly  cooked  and  protected  against  contamination  by  flies,  etc. 

13.  At  ports  where  yellow  fever  prevails,  in  addition  to  the  other 
measures  presented  hereafter,  ^precautions  should  be  taken  to  prevent 
the  introduction  of  mosquitoes  on  board  the  vessel.  Water-tanks, 
water-buckets,  and  other  collections  of  water  about  the  .vessel  should 
be  guarded  in  such  a  manner  that  they  shall  not  become  breeding- 
places  for  mosquitoes.  Measures  should  also  be  taken  to  destroy 
mosquitoes  that  may  have  come  on  board.  Baggage  destined  directly 
or  indirectly  for  any  State  should  be  disinfected  at  the  request  of  the 
health  officer  of  said  State.  All  baggage  from  such  ports  must  be 
rigidly  inspected  and  the  exclusion  of  mosquitoes  assured. 

14.  At  ports  or  places  where  plague,  prevails,  every  precaution 
must  be  taken  to  prevent  the  vessel  becoming  infected  through  the 
agenc)''  of  rats,  ants,  flies,  fleas,  or  other  animals.  At  such  ports  or 
places  the  vessel  should  not  lie  at  a  dock,  or  tie  to  the  shore,  or  anchor 


FOREIGN  QUARANTINE.  479 

near  any  j^lace  where  such  animals  may  gain  access  to  the  vessel.  In 
case  cables  are  led  to  the  shore  they  should  be  freshly  tarred  and 
provided  with  inverted  cones  or  such  other  devices  as  may  prevent 
rats  and  other  animals  passing  to  the  ship.  The  introduction  of 
vermin  on  board  the  vessel  from  lighters  and  all  other  sources  should 
be  guarded  against.  In  such  ports  sulphur  fumigation  should  be 
resorted  to  in  the  holds  when  empty  and  from  time  to  time  during 
loading  in  order  to  destroy  vermin. 

15.  At  all  infected  ports  or  places,  communication  between  the 
vessel  and  shore  should  be  reduced  to  a  minimum. 

16.  Vessels  carrying  passengers  from  any  port  or  place  where 
quarantinable  disease  prevails  in  epidemic  form  should  have  one  med- 
ical officer;  and  from  ports  where  cholera  or  plague  prevails  in  epi- 
demic form  should  have  two  medical  officers  if  more  than  350  passen- 
gers are  carried. 

Cargo. 

17.  Earth,  loam,  soft  or  porous  rock  should  not  be  taken  as  bal- 
last at  ports  infected  with  cholera  or  plague.  Street-sweepings,  city 
cleanings,  or  anything  containing  organic  refuse  should  not  be  taken 
as  ballast  from  any  port.  Where  practicable,  hard  rock  or  clean  beach 
sand  or  sea-water  ballast  should  be  given  preference. 

18.  Household  goods,  personal  effects,  bedding,  and  second-hand 
articles  generally,  coming  from  a  district  known  to  be  infected  with 
cholera,  small-pox,  typhus  fever,  or  plague,  or  as  to  the  origin  of 
which  no  positive  evidence  can  be  obtained,  and  which  the  consular  or 
medical  officer  has  reason  to  believe  are  infected,  should  be  disinfected 
prior  to  shipment.  Measures  should  be  taken  with  articles  of  this 
class  from  districts  infected  with  yellow  fever  to  insure  their  freedom 
from  mosquitoes. 

19.  New  merchandise  in  general  may  be  accepted  for  shipment 
without  restriction,  and  articles  of  new  merchandise — textile  fabrics 
and  the  like — which  have  been  packed  or  prepared  for  shipment  in  an 
infected  port  or  place,  with  a  special  view  to  protect  the  same  from 
moisture  incident  to  the  voyage,  may  be  accepted  and  exempted  from 
disinfection. 

20.  Certain  food  products,  \\%.,  unsaltcd  meats,  sausages,  dressed 
poultry,  fresh  butter,  fresh  milk  (unsterilized),  fresh  cheese,  coming 
from  cholera-infected  localities  or  through  such  localities,  if  exposed 
to  infection  therein,  should  not  be  shipped.  Fresh  fruits  and  vege- 
tables, from  districts  where  cholera  prevails,  shall  be  shipped  only 


480  TEXT-BOOK  OF  HYGIENE. 

under  sucli  sanitary  supervision  as  will  enable  the  inspector  to  certify 
t:liat  they  have  not  been  exposed  to  infection. 

21.  All  rags  and  textile  fabrics  used  in  the  manufacture  of  paper 
and  for  other  purposes  which  are  collected,  packed,  or  handled  in  any 
foreign  port  or  place,  with  the  exceptions  as  hereinafter  specified, 
shall,  prior  to  shipment  to  the  United  States,  be  subjected  to  disinfec- 
tion bygone  of  the  prescribed  methods.  (Jute  bags  or  bagging  used 
in  baling  cotton,  old  rope,  new  cotton,  or  linen  cuttings  from  factories 
not  included.)  The  disinfection  of  the  articles  mentioned  above  shall 
be  performed  under  the  supervision  of  a  United  States  consul  or  a 
medical  officer  of  the  United  States,  and  a  certificate  in  duplicate, 
signed  b}'  said  consul  or  medical  officer,  shall  be  issued  with  each  con- 
signment of  same,  v\-hich  certificate  shall  identify  the  articles  and  state 
that  they  have  been  disinfected  in  accordance  v>'ith  the  United  States 
quarantine  regulations.  The  original  certificate  of  disinfection  shall 
be  attached  to  the  consignee's  invoice,  and  where  the  articles  are  car- 
ried by  sea  the  duplicate  certificate  of  disinfection  shall  be  attached  to 
the  bill  of  health  issued  to  the  vessel  conveying  the  same. 

Excepiions. — Such  articles  shipped  from  the  dominion  of  Canada 
directly  to  the  United  States  shall  be  exempt  from  this  requirement 
if  accompanied  by  affidavits  demonstrating  to  the  satisfaction  of  the 
collector  of  customs  at  the  port  of  arrival  that  they  have  actuar.y 
originated  in  Canada  and  have  not  been  shipped  from  a  foreign  country 
to  Canada,  and  thence  shipped  to  the  United  States ;  and  further,  that 
the  port  or  place  where  collected  or  handled  has  been  free  from  quar- 
antinable  diseases  for  thirty  days  prior  to  shipment. 

23.  Xew  feathers  for  bedding,  human  and  other  hair  (unmanu- 
factured), bristles,  wool,  hides  not  chemically  cured,  coming  from  a 
district  where  cholera  or  plague  prevails,  shall  be  refused  entry  into 
the  United  States  until  thirty  days  have  elapsed  since  last  exposure 
in  case  of  cholera,  and  sixty  days  in  case  of  plague,  unless  unpacked 
and  disinfected.  Feathers  which  have  been  used  should  be  disinfected, 
and  invariably  by  steam. 

Bristles  which  have  been  Ijoiled,  and  wool  and  new  feathers  which 
have  been  packed  in  naphthalin  preparatory  to  shipment,  may  be 
shipped  without  further  treatment. 

Dry  hides  packed  in  naphthalin  may  be  shipped  as  chemically 
cured  hides. 

Unsalted  green  hides  from  a  district  where  cholera  prevails  must 
not  be  shipped. 

23.  The  articles  enumerated  in  the  preceding  paragraph  coming 


1 


FOREIGN  QUARANTINE.  481 

from  a  district  where  small-pox,  typhus  fever,  cholera,  or  plague  pre- 
vails in  epidemic  form,  should  be  refused  shipment  unless  disinfected 
as  hereinafter  provided. 

24.  jSTothing  in  these  regulations  shall  be  construed  to  modify  or 
affect  in  any  way  any  existing  restrictions  promulgated  by  the  secre- 
tary of  the  Treasury  at  the  instance  of  the  Bureau  of  Animal  Industry, 
Department  of  Agriculture,  regarding  the  importation  of  hides  of 
neat  cattle. 

25.  Any  covering,  shipped  from  or  through  an  infected  port  or 
place,  and  which  the  consul  or  medical  officer  has  reason  to  believe 
infected,   should  be   disinfected. 

26.  Any  article  presumably  infected,  which  can  not  be  dis- 
infected should  not  be  shipped. 

Passengers  and  Crew. 

27.  Passengers,  for  the  purposes  of  these  regulations,  are  divided 
into  two  classes :   cabin  and  steerage. 

28.  When  practicable,  passengers  should  not  ship  from  an  infected 
port. 

29.  No  person  suffering  from  a  quarantinable  disease,  or  scarlet 
fever,  measles,  diphtheria,  or-  other  communicable  disease,  should  be 
allowed  to  ship. 

30.  Steerage  passengers  and  crew  coming  from  cholera-infected 
districts  should  be  detained  five  days  in  suitable  houses  or  barracks 
located  where  there  is  no  danger  from  infection,  and  all  baggage 
disinfected. 

31.  Steerage  passengers  and  crew  from  districts  not  infected  with 
cholera,  shipping  at  a  port  infected  with  cholera,  unless  passed  through 
without  danger  of  infection  and  no  communication  allowed  between 
such  persons  and  the  infected  locality,  should  be  treated  as  those  in 
the  last  paragraph. 

32.  Cabin  passengers  coming  from  cholera-infected  districts  em- 
barking at  a  clean  or  an  infected  port  should  produce  satisfactory 
evidence  as  to  their  exact  places  of  abode  during  the  five  days  imme- 
diately preceding  embarkation.  And  if  it  appears  that  they  or  their 
baggage  have  been  exposed  to  infection,  the  baggage  should  be  disin- 
fected and  the  passengers  detained  under  medical  supervision  a  suffi- 
cient time  to  cover  the  period  of  incubation  since  last  exposure. 

33.  Steerage  passengers  and  crew  who,  in  the  opinion  of  the  inspect- 
ing officer,  have  been  exposed  to  the  infection  of  yellow  fever,  should 


4S2  TEXT-BOOK  OF  HYGIENE. 

be  held  under  medical  observation  in  a  place  free  from  danger  of 
infection  for  a  period  of  five  da3^s  before  embarkation. 

34.  Steerage  passengers  and  crew,  coming  from  districts  where 
small-pox  prevails  in  epidemic  form,  or  who  have  been  exposed  to 
small-pox,  should  be  vaccinated  before  embarkation,  unless  they  show 
evidence  of  having  acquired  immunity  to  small-pox  by  previous  attack 
or  recent  successful  vaccination. 

35.  Steerage  passengers  and  crew  who,  in  the  opinion  of  the  in- 
specting officer  have  been  exposed  to  the  infection  of  typhus  fever, 
should  not  be  allowed  to  embark  for  a  period  of  at  least  twelve  days 
after  such  exposure  and  the  disinfection  of  their  baggage. 

36.  Steerage  passengers  and  crew  who,  in  the  opinion  of  the  in- 
specting officer,  have  been  exposed  to  the  infection  of  plague  should 
be  held  under  medical  observation  in  a  place  free  from  danger  of 
infection  for  a  period  of  seven  days  before  embarkation,  and  their 
baggage  disinfected. 

37.  Cabin  passengers  coming  from  plague-infected  districts, 
whether  embarking  at  a  clean  or  an  infected  port,  should  produce 
satisfactory  evidence  as  to  their  exact  places  of  abode  during  the  seven 
days  immediately  preceding  embarkation.  And  if  it  appears  that  they 
or  their  baggage  have  been  exposed  to  infection  the  baggage  should 
be  disinfected  and  the  passengers  detained  under  medical  supervision 
a  sufficient  time  to  cover  the  period  of  incubation  since  the  last  ex- 
posure, 

38.  Should  quarantinable  disease  appear  in  the  barracks  or 
houses  in  which  passengers  are  undergoing  detention,  no  passenger 
from  said  houses  or  barracks  who  has  been  presumably  exposed  to 
this  new  infection  shouM  embark  until  after  the  expiration  of  the 
period  of  incubation  of  the  disease  in  question  subsequent  to  the  last 
expostire  to  infection  and  the  application  of  all  necessary  sanitary 
measures. 

39.  All  baggage  of  steerage  passengers  destined  for  the  United 
States  should  be  labeled.  If  the  baggage  is  in  good  sanitary  condi- 
tion the  label  shall  be  a  fed  label  bearing  the  name  of  the  port,  the 
steamship  on  which  the  baggage  is  to  be  carried,  the  word  "passed" 
in  large  type,  the  date  of  inspection,  and  the  seal  or  stamp  of  the 
consular  or  medical  officer  of  the  United  States.  All  baggage  that  has 
been  disinfected  shall  bear  a  yellow  label,  upon  which  shall  be  printed 
the  name  of  the  port,  the  steamship  upon  which  the  baggage  is  to  be 
carried,  the  word  "disinfected"  in  large  type,  the  date  of  disinfection, 
and  the  seal  or  stamp  of  the  consular  or  medical  officer  of  the  United 


FOREIGN  QUARAXTIXI';. 


4H^i 


INSPECTION  CARD. 

[Immigrants  and  Steerage  Passengers.] 

Port  of  departure Date  of  departure  

Name  of  ship .  Last  permanent  residencs 


Name  of  immisrrant 


Inspected  and  passed 


[Seal  or  stamp  of  consular  or 
medical  officer.] 


Passed  at  quarantine,  port  of 
United  States. 


Passed  by  Immigration  Bu- 
reau, port  of 


[Date.] 


[Bate. 


[The  following  to  be  filled  in  by  ship's  surgeon  or  agent  prior  to  or  after  embarkation.] 
Ship's  list  or  manifest .     No.  on  ship's  list  or  manifest 


Berth  No. 


a  B-Sa 


(N      CO      -^ 


VACCINATED. 

[Signature  or  Stamj).] 
[Reverse  Side.] 

Keep  this  Card  to  avoid  detention  at  Quarantine  and  on  Railroads  in 
the  United  States. 


Diese  Karte  muss  aufbewahrt  werden,  um  Aufenthalt  an  der  Quaran- 
tine, sowie  auf  den  Eisenbahnen  der  Vereinisrten  Staaten  zu  vermeiden. 


Cette  carte  doit  etre  conservee  pour  eviter  inie  detention  a  la  Quaran- 
taine,  ainsi  que  sur  les  chemins  ds  fer  des  Etats-Unis. 


Deze  kaart  moet  bewaard  worden,  ten  einde  oponthoud  aan  de  Quar- 
antijn,  alsook  op  de  ijzeren  wegen  der  Vereenigde  Staten  te  vermijden. 


Conservate  questo  biglietto  onde  evitare   detenzione   alia   Quarantina 
e  sulle  Ferrovie  degli  Stati  Uniti. 


Tento    llstek    musite    uschovati,    nechcete-li    ukaranteny     (zastavenf 
oliledng  zjistOni  zdravf)   neb  na  drflze  ve  spojenych  statech  zdrzeni  byti. 


Tuto    kartocku    trcba    trimat'    u    sebe   aby    sa    predeslo    zderzovanu   v 
karanterie  aj  na  zeleznici  ve  Spojench  StAtoch. 


484  TEXT-BOOK  OF  HYGIENE. 

States.  It  is  understood,  and  it  will  be  so  printed  on  the  blank,  that 
the  label  is  not  valid  unless  bearing  the  consular  or  medical  officer's 
stamp  or  seal. 

40.  Each  steerage  passenger  shall  be  furnished  with  an  inspection 
card  (see  page  483).  This  card,  stamped  by  the  consular  or  medical 
officer,  is  to  be  issued  to  every  member  of  a  family  as  well  as  to  the 
head  thereof.    ' 

41.  In  a  port  where  any  quarantinable  disease  prevails,  the  per- 
sonnel of  vessels  should  remain  on  board  during  their  stay  in  such  port. 

42.  Passengers  and  crews,  merchandise  and  baggage,  prior  to 
shipment  at  a  noninfected  port,  but  coming  from  an  infected  locality, 
should  be  subject  to  the  same  restrictions  as  are  imposed  at  an  in- 
fected port. 

Eecords,  Eeports,  Etc. 

43.  The  officer  making  the  inspection  will  preserve  in  his  office  a 
record  of  each  inspection  made  and  of  each  immunity  certificate 
given;  a  copy  of  each  certificate  of  disinfection  and  of  each  bill  of 
health  issued. 

A  weekly  report  of  the  transactions  of  his  office  shall  be  for- 
warded to  the  Surgeon-General  at  Washington,  D.  C. 

44.  In  addition  to  the  duties  prescribed,  the  medical  officer  when 
detailed  in  accordance  with  the  act  of  Congress  approved  February 
15,  1893,  shall  furnish  such  reports  to  the  Surgeon-General  of  the 
Public  Health  and  Marine-Hospital  Service  as  he  may  be  able  to 
make  upon  sanitary  conditions  and  other  matters  affecting  the  public 
health  and  the  welfare  of  the  Service  administration. 

Requirements  at  Sea} 

45.  The  master  of  a  vessel  should  observe  the  following  measures 
or.  board  his  vessel: — 

(a)  The  water-closets,  forecastle,  bilges,  and  similar  portions  of 
the  vessel  liable  to  harbor  infection  should  be  disinfected  and  fre- 
quently cleansed. 

(&)  Free  ventilation  and  rigorous  cleanliness  should  be  main- 
tained in  all  portions  of  the  ship  during  the  voyage  and  measures 
taken  to  destroy  rats,  mice,  fleas,  flies,  roaches,  mosquitoes,  and  other 
vermin. 

(c)   A  patient  sick  of  a  communicable  disease  should  be  isolated 


^  These  requirements  are  largely  advisory  in  character,  but  it  is  never- 
theless true  that  a  careful  compliance  with  them  should  tend,  at  the  port 
of  arrival,  to  largely  relieve  the  stringency  of  quarantine  measures. 


FOREIGN  QUARANTINE.  485 

and  one  member  of  the  crew  detailed  for  his  care  and  comfort,  who, 
if  practicable,  should  be  immune  to  the  disease. 

(d)  Communication  between  the  patient  or  his  nurse  and  other 
persons  on  board  should  be  reduced  to  a  minimum. 

(e)  Used  clothing,  body  linen,  and  bedding  of  the  patient  and 
nurse  should  be  immersed  at  once  in  boiling  water  or  in  a  disinfect- 
ing solution. 

(/)  The  compartment  from  which  the  joatient  was  removed 
should  be  disinfected  and  thoroughly  cleansed.  Articles  liable  to  con- 
vey infection  should  remain  in  the  compartments  during  the  disin- 
fection when  gaseous  disinfection  is  used. 

(g)  Any  person  suffering  from  malaria  or  yellow  fever  should 
be  kept  under  mosquito  bars  and  the  apartment  in  which  he  is  confined 
closely  screened  with  mosquito  netting.  All  mosquitoes  on  board 
should  be  destroyed  by  burning  pyrethrum  powder  (Persian  insect 
powder)  or  by  fumigation  with  sulphur.  Mosquito  larvge  (wigglers 
or  wiggle-tails)  should.be  destroyed  in  water-barrels,  casks,  and  other 
collections  of  water  about  the  vessel  by  the  use  of  petroleum  (kero- 
sene) ;  where  this  is  not  practicable,  use  mosquito  netting  to  prevent 
the  exit  of  mosquitoes  from  such  breeding-places. 

(Ji)  In  the  case  of  plague,  special  measures  must  be  taken  to  de- 
stroy rats,  mice,  fleas,  flies,  ants,  and  other  vermin  on  board. 

(i)  In  the  case  of  cholera,  typhoid  fever,  or  dysentery,  the  drink- 
ing water  should  be  boiled  and  the  food  thoroughly  cooked.  The  dis- 
charges from  the  patient  should  be  immediately  disinfected  and 
thrown  overboard. 

46.  An  inspection  of  the  vessel,  including  the  steerage,  should  be 
made  by  the  ship's  physician  once  each  day. 

47.  Should  cholera,  yellow  fever,  small-pox,  typhus  fever,  plague, 
or  any  other  communicable  disease  appear  on  board  ship  while  at 
sea,  those  who  show  symptoms  of  these  diseases  should  be  immediately 
isolated  in  a  proper  place ;  the  ship's  physician  should  then  immedi- 
ately notify  the  captain,  who  should  note  same  in  his  log,  and  all  of 
the  effects  liable  to  convey  infection  which  have  been  exposed  to  infec- 
tion should  be  destroyed  or  disinfected. 

48.  The  hospital  should  be  disinfected  as  soon  as  it  becomes 
vacant. 

4'.}.  The  dcfid  should  1)0  enveloped  in  a  sheet  saturated  with  one 
of  the  strong  disinfecting  solutions,  without  previous  washing  of  the 
body,  and  at  once  buried  at  sea  or  placed  in  a  coffin  hermetically 
eealed. 


486  TEXT-BOOK  OF  HYGIENE. 

50.  A  complete  clinical  record  should  be  kept  by  the  ship's  sur- 
geon of  all  cases  of  sickness  on  board,  and  the  record  delivered  to  the 
quarantine  officer  at  the  port  of  arrival. 

51.  The  following  disinfecting  solutions  are  recommended  for  use 
at  sea : — 

Formulce  for  strong  disinfecting  solutions. 

BiCHLOKIDE    OF    MERCURY.        (1:500.)  ♦ 

Bichloride    of    mercury 1  part 

Sea   water 500  parts 

Mix. 

Carbolic  Acid.     (5  per  cent.) 

Alcohol     50  parts 

Carbolic  acid,  pure 50  parts 

Mix. 

Then  add  fresh  water 900  parts 

^  Formulce  for  weak  solutions. 

BiCHLOKIDE    OF    MeRCUBY.       (1:1,000.) 

Bichloride  of  mercury 1  part 

Sea   water 1000  parts 

Carbolic  Acid.     (2%  per  cent.) 

Carbolic    acid,    pure 25  parts 

Fresh   water 1000  parts 

Formalin.      (5  per  cent.) 

Formalin    (or   forraol) 50  parts 

Water   950  parts 

It  is  suggested  that  a  vessel  should  carry  for  every  100  passengers : 
bichloride  of  mercury,  5  pounds;  carbolic  acid,  10  pounds;  alcohol, 
10  pounds,  and  formalin,  10  pounds. 

EFFICIENCY   OF   FOREIGN   REGULATIONS. 

The  wisdom  of  this  method  of  procedure  and  the  efficient  working 
of  these  regulations  are  demonstrated  by  the  following  statement 
taken  from  the  report  of  the  medical  officer  of  the  Marine-Hospital 
Service  on  duty  at  Naples,  Italy,  where,  during  the  summer  of  1893, 
cholera  was  epidemic: — 

"From  the  15th  of  July  to  August  17th  there  were  eight  vessels 
cleared  from  Naples  with  steerage  passengers — four  for  New  York  and 


FOREIGN  QUARANTINE.  487 

four  for  South  American  ports.  The  first  to  leave  was  the  Karamania, 
for  ISTew  York,  on  July  15th.  No  cholera  at  that  time  existed  in 
Naples.  The  first  case  occurred  in  Naples  on  the  night  of  the  16th, 
and  the  result  of  the  bacteriological  examination  was  not  known  until 
the  afternoon  of  the  17th  or  morning  of  the  18th. 

"The  passengers  for  the  Karamania  and  the  ship  itself  were  put 
through  the  established  routine.  The  ship  was  cleaned;  ventilation, 
etc.,  altered  to  conform  with  the  United  States  law;  closets  and  hos- 
pitals put  in  good  order;  water-  and  food-  supply  attended  to;  pas- 
sengers inspected  and  vaccinated,  and  both  their  baggage  and  clothing 
searched  for  food.  Three  days  after  sailing,  i.e.,  on  the  18th,  a  death 
from  cholera  occurred,  and  just  before  reaching  New  York  there  were 
two  more.  It  is  not  unlikely  that  the  infection  in  the  first  cases  was 
traceable  to  the  same  source  as  those  occurring  in  Naples  on  the  16th. 
It  is  more  than  probable  that  but  for  the  careful  exclusion  of  food 
brought  by  passengers  there  would  have  been  more  cases  on  the  re- 
maining three  ships  for  the  United  States.  The  regulations  govern- 
ing infected  ports  were  rigidly  enforced.  The  first  vessel  to  leave,  four 
days  after  the  cholera  was  announced,  was  the  Massilia.  Her  passen- 
gers were  met  at  the  trains  and  conducted  immediately  on  board; 
were  there  isolated  three  days,  and  all  their  baggage  transferred  across 
city  unopened.  All  food  was  carefully  looked  into;  all  from  persons 
or  baggage  excluded;  and  the  baggage  of  a  few,  about  whose  ante- 
cedents there  was  doubt,  disinfected  by  steam.  The  ship  was  warped 
out  some  distance  from  the  pier  every  night,  and  an  inspector  kept  on 
board  night  and  day.  There  being  no  cholera  known  to  exist  anywhere 
in  Italy  outside  of  Naples,  it  was  not  thought  necessary  to  disinfect 
all  baggage  or  isolate  for  five  days.  She  arrived  safely  in  New  York 
without  mishap.  The  remaining  two  for  the  United  States  were  the 
Weser  and  Cashmire;  in  both  cases  the  regulations  were  enforced  in 
detail.  One  lay  about  a  mile  and  a  half  otf  shore  during  her  five  days. 
The  other  cruised  at  sea.  In  both  cases  an  inspector  was  kept  aboard 
day  and  night.     Both  escaped  cholera. 

"The  four  for  South  America,  with  the  result  in  each  case,  were 
as  follows :  The  figures  are  not  official,  l)ut  are  practically  accurate  in 
every  respect.  All  were  turned  back  by  the  South  American  author- 
ities: Vencinzio  Florio — about  50  deaths;  Andrea  Dorio — 90  on 
way  out,  total  not  ascertained;  El  Remo — 84  deaths;  Carlo  R. — 
about  230  deaths. 

"To  summarize,  then,  eight  ships  left  Naples.  The  water-supply 
was  the  same  and  the  food  nbont  the  same;    tlie  class  of  passengers 


TEXT-BOOK  OF  HYGIENE. 

identical,  and  their  places  of  origin  similar — in  many  cases  identical. 
All  four  leaving  without  precautions  became  floating  pest-houses.  Of 
the  four  for  the  United  States  the  one  leaving  before  cholera  appeared 
in  Naples  had  three  deaths;  the  other  three  were  made  to  conform 
to  the  regulations,  and  all  escaped.  In  other  words,  every  ship  that 
left  Naples  had  cholera  except  those  in  whose  case  the  'infected  port' 
regulations  were  carried  out;  and  of  the  five  that  had  cholera,  the 
only  one  that  escaped  with  less  than  50  deaths  was  the  one  on  which 
our  'non-infected  port'  regulations  were  enforced,  she  having  only  3 
deaths  en  route.  In  addition,  the  enforcement  of  the  regulations 
compelled  the  abandonment  of  a  number  of  other  sailings  for  the 
United  States.  The  escape  of  the  Massilia,  Cashmire,  and  Weser  may 
be  'post,^  not  'proper  hoc,'  but  we  certainly  have  the  right  to  consider 
the  evidence  to  be  strongly  on  the  side  of  'propter.' " 

DOMESTIC  QUARANTINE. 

The  trans-oceanic  part  of  the  voyage  completed,  the  vessel  ar- 
rives in  the  waters  of  the  United  States,  and  here  she  is  confronted  by 
a  municipal.  State,  or  national  quarantine  station,  where  the  ques- 
tion will  be  determined  whether  the  measures  prescribed  have  been 
carried  out,  whether  they  have  been  effective  in  the  particular  case, 
and,  in  fine,  whether  the  vessel,  her  crew,  passengers,  and  cargo,  are 
or  are  not  a  menace  to  the  health  of  the  city  and  the  country  at  large. 

MARITIME  QUARANTINE  STATIONS. 

In  describing  a  maritime  quarantine  station  it  should  be  borne  in 
mind  that  the  details  in  the  plant  must  vary  in  accordance  with  the 
special  demands  of  each  port. 

Thus,  it  is  not  to  be  expected  that  at  Charleston,  where  immigra- 
tion is  limited,  there  should  be  the  same  provisions  for  detention  of 
immigrants  as  at  New  York,  through  whose  portals  more  than  one- 
third  of  a  million  of  immigrants  pass  each  year;  or  San  Francisco, 
where  enter  the  throng  of  travelers  and  immigrants  from  the  far  East. 

We  should  not  expect  that  Boston,  in  the  more  salubrious  North, 
would  have  the  means  or  adopt  the  practice  of  discharging  ballast, 
cleaning  and  fumigating  every  vessel  from  an  infected  port,  which 
is  the  invariable  custom  at  Pensacola. 

But,  leaving  these  variations  for  subsequent  notice,  the  first 
thing  to  be  considered,  in  the  establishment  of  a  complete  mari- 
time quarantine,  is  proper  location.     This  must  be  at  a  point  remote 


DOMESTIC  QUARANTINE.  489 

from  city  or  village  boundaries,  and  not  likely  to  be  encroached  upon 
by  urban  growth.  It  should  be  more  or  less  removed  from  the  chan- 
nels of  commerce,  and  yet  be  easily  accessible.  Indifference  to  proper 
location  could  very  readily  make  the  quarantine  station  a  source  of 
danger  instead  of  a  protection. 

THE  QUARANTINE  PLANT. 

The  requirements  of  a  maritime  quarantine  station  may  be  enu- 
merated as  follows:  1.  A  boarding-station.  2.  A  boarding-vessel. 
3.  Anchorages.  4.  Wharves  with  warehouse,  disinfecting  machinery, 
and  machinery  for  discharge  of  ballast.  5.  Lazaretto,  or  hospital  for 
treatment  of  contagious  diseases.  6.  Hospital  for  treatment  of  non- 
contagious diseases.  7.  Barracks  for  the  detention,  in  groups,  of  sus- 
pects, or  persons  who  have  been  exposed  to  contagion  or  infection. 
8.  Bath-house.  9.  Water-supply.  10.  A  cremation  furnace.  11. 
Quarters  for  medical  officers.     12.  Laundry. 

1.  The  Boarding-station. — This  includes  a  boat-house,  with  boat- 
men's quarters  so  located  as  to  avoid  infection  from  the  Lazaretto,  and 
to  be  within  easy  reach  of  passing  commerce. 

2.  Boarding-vessel. — The  facilities  for  boarding  and  inspection 
will  vary  with  the  location  of  the  station,  whether  within  the  limits 
of  a  land-locked  harbor  or  exposed  to  the  full  force  of  wind  and  sea. 
In  the  former  case  a  steam-  or  naphtha-  launch,  or  even  a  row-boat, 
will  suffice;  but  in  the  latter  case  the  boarding-boat  must  be  a 
steamer,  preferably  of  the  sea-going  tug-boat  type,  for  it  must  be 
remembered  that  any  delay  in  making  the  inspection  inflicts  hard- 
ship on  commerce,  and  must  inevitably  produce  discontent  and 
complaint. 

3.  Anchorages. — Two  anchorages,  one  for  infected  and  one  for 
non-infected  vessels.  The  anchorage  for  the  detention  of  the  infected 
vessel  should  be  conveniently  removed  from  the  main  establishment 
and  safely  remote  from  the  track  of  commerce.  Its  position  should 
be  sheltered,  and  good  holding-ground  for  vessels'  anchors  is  of  the 
first  importance.  The  channel  to  the  anchorages,  and,  if  necessary, 
their  boundaries,  should  be  plainly  marked  by  buoys. 

4.  Wharves. — A  wharf  or  pier  is  a  prime  essential  in  the  equip- 
ment of  a  complete  station,  and  should  be  located  in  water  at  least 
twenty  feet  deep,  and  should  be  of  such  length  that  the  largest  ves- 
sels trading  at  the  port  can  lie  there  safely;  at  least,  in  all  ordin- 
ary weather.  Upon  this  wharf  there  should  be  a  warehouse  for  the 
Btorage  of  baggage  and  portions  of  cargo  (practically,  cargo  is  never 


490  TEXT-BOOK  OF  HYGIENE. 

fully  discharged,  being  disinfected  in  situ).  On  the  wharf  should  be 
placed  the  steam  disinfecting  chambers,  sulphur-furnaces,  and  tanks 
for  holding  disinfecting  solutions.  (At  certain  stations  the  disinfect- 
ing apparatus  is  necessarily  placed  on  a  barge.)  When  required,  a 
special,  additional  wharf  should  be  provided  for  the  discharge  of 
ballast. 

Steam  Disinfecting'  Chambers. — The  principle  of  disinfection  by 
steam  was  first  advocated  by  Dr.  A.  N.  Bell,  of  Brooklyn;  but  tho 
credit  of  first  designing  apparatus  for  the  special  purpose  belongs 
to  Dr.  Joseph  Holt,  and  his  design  was  subsequently  improved  upon 
by  Dr.  Wilkinson  and  others. 

Steam  Chambers. — These  chambers  consisted  of  cylindrical 
shells,  made  of  strong  boiler-iron,  40  to  50  feet  long  and  7  to  8  feet 
in  diameter  (inside  measurement),  furnished  with  doors  at  each  end. 
The  steam  was  admitted  directly  to  the  interior  of  the  chamber,  and 
in  addition  there  was  a  coil  of  pipe  for  the  application  of  dry  heat. 
These  chambers  were  fairly  efficient  in  action,  but  there  was  a  great 
waste  of  space,  and  with  the  exercise  of  every  possible  care  there  was 
always  more  or  less  wetting  of  fabrics  by  the  water  of  condensation. 
Many  improvements  have  been  made  from  time  to  time  in  the  con- 
struction of  steam  disinfecting  chambers,  those  constructed  for  the 
national  quarantine  station  at  San  Francisco,  Cal.,  being  of  the  same 
general  construction,  but  dispensing  with  the  coil  of  pipe,  and  substi- 
tuting therefor   a  jacket   surrounding   the   entire   chamber. 

The  most  recent  steam  chambers  are  of  rectangular  section,  16 
feet  in  length,  4  feet  6  inches  in  width,  and  5  feet  6  inches  in  height, 
and  are  provided  with  steam-tight  doors  opening  at  either  end.  The 
chambers  are  constructed  of  an  inner  and  outer  steel  shell  2i/2  inches 
apart,  with  cast-iron  end  frames,  intermediate  truss  bands,  and  of  stay- 
bolt  construction. 

The  doors  have  concave  steel  plates  riveted  to  cast  angle  frames 
fitted  with  heavy  rubber  gaskets;  they  are  handled  by  convenient 
cranes,  and  drawn  tight  by  drop-forged  steel  eye-bolts,  swinging  in 
and  out  of  slots  in  the  door-frames.  The  rectangular  form  is  adopted 
in  preference  to  the  round,  as  it  gives  the  most  effective  space  during 
exposure,  with  little  loss  of  steam,  and  enables  cars  on  tracks  to  be 
readily  handled  in  and  out.  The  jacket  is  used  to  give  perfect  circula- 
tion and  distribution  of  heat,  to  prevent  condensation,  and  to  dry  the 
goods  exposed.  The  jackets,  which  are  filled  with  steam  during  the 
entire  operation  of  the  plant,  make  the  chambers  drying  ovens;  so 
that  tlie  articles  to  be  disinfected  are  brought  to  the  required  tempera- 


DOMESTIC  QUARANTINE.  491 

ture  before  the  admission  of  steam  to  the  inner  chamber,  and  are 
thoroughly  dried  after  the  steam  has  been  exhausted. 

In  the  experiments  of  Professor  Koch  in  connection  with  Dr. 
Wollfhiigel  it  was  found  that  hot  air  alone,  even  at  a  temperature  of 
230°  to  248°  F.,  after  an  exposure  of  three  hours,  would  not  with 
certainty  destroy  bacilli  and  spores.  It  is  necessary,  therefore,  to 
eliminate  the  possibility  of  the  pocketing  of  air,  or  of  a  mixture  of  air 
and  steam,  during  exposure.  To  prevent  this  an  inspirator  is  attached 
to  the  system  of  piping,  whereby  a  vacuum  of  10  to  15  inches  is  pro- 
duced in  the  chamber  prior  to  the  admission  of  steam.  In  previous 
chambers  this  important  point  was  neglected,  and  this  accounts  for 
the  unreliable  results  obtained  by  a  number  of  disinfecting  plants. 

For  convenience  of  handling  the  goods  to  be  disinfected,  each 
chamber  is  provided  with  two  cars  of  light  wrought-iron  construction, 
with  removable  trays  with  bottoms  of  galvanized-iron  wire-  netting, 
and  having  a  series  of  bronze  wardrobe-hooks  in  the  top  of  the  frame- 
work, thus  permitting  the  articles  to  be  laid  out  upon  the  trays,  or  in 
the  case  of  finer  clothing,  to  be  hung  upon  the  hooks.  The  doors  at 
both  ends  allow  the  cars  to  be  brought  in  at  one  end  and  removed 
at  the  other,  thus  securing  complete  separation  of  infected  and  disin- 
fected articles.  After  exposure  the  cars,  upon  being  unloaded,  are 
returned  to  the  working  end  of  the  chamber  by  means  of  transfer 
tables  and  side-tracks,  permitting  a  continuous  working  of  the  plant. 

The  system  of  piping  is  so  arranged  that  steam  may  be  admitted 
to  the  top  or  bottom  of  the  chamber  at  will,  through  several  openings, 
and  has  perfect  circulation.  Galvanized-iron  hoods  are  placed  in  the 
chambers,  so  that  steam  is  not  forced  directly  on  the  clothing.  The 
chamber  is  provided  with  thermometers  to  register  the  temperature, 
vacuum  and  steam-gauges,  safety-valves,  traps,  and  is  covered  with 
magnesia  non-conducting   covering. 

Sulphur-furnace. — For  a  long  time  the  method  of  sulphur  fumi- 
gation pursued  was  to  put  into  iron  pots  a  quantity  of  sulphur  vary- 
ing from  three  to  four  pounds  to  one  thousand  cubic  feet,  igniting  this 
by  means  of  alcohol,  and  to  place  them  in  the  hold  or  apartment  to 
be  disinfected.  An  apparatus  has  been  designed  for  the  purpose  of 
producing  SOg  in  greater  percentage,  and  consists  of  a  furnace  built 
on  the  reverberatory  plan,  with  a  series  of  shelves  arranged  one  above 
another,  each  shelf  carrying  a  pan  of  burning  sulphur.  A  forced 
draught  is  kept  up  by  means  of  a  fan-blower  connected  at  the  bottom. 
The  draught  of  air  charged  from  the  burning  sulphur  is  made  to 
reach  and  pass  over  the  shelP  above  by  means  of  apertures  made  by 


492  TEXT-BOOK  OF  HYGIENE. 

shortening  the  shelves  alternately  at  their  rear  and  front  extremities. 
With  an  experimental  furnace,  Dr.  Kinyoun  states  that  "repeated 
experiments  gave  from  14  to  16  per  cent,  of  SO2,  temperature  31° 
C,  while  burning  sulphur  in  a  closed  place  gave  only  6  per  cent, 
at  21°  C. — i.e.,  the  air  would  not  support  the  combustion  of  sulphur 
above  that  percentage." 

This  has  been  almost  entirely  superseded  by  a  furnace  that  is 
simpler  in  construction,  and  which  has  given  admirable  results  in 
practice.  The  furnace  is  double,  and  has  been  provided  with  small 
fire-boxes  at  each  end,  over  which  are  placed  two  shallow  cast-iron 
pans  five  feet  long,  and  the  whole  inclosed  in  a  frame  of  sheet-iron. 
The  sulphur  is  placed  in  the  pans  and  a  fire  lighted  in  the  furnaces, 
melting  the  sulphur,  which  quickly  ignites.  To  prevent  too  rapid 
combustion  baffle  plates  are  arranged,  and  the  proper  quantity  of  air 
is  admitted  through  adjustable  valves  in  the  furnace-fronts.  The 
fumes  of  sulphur  dioxide  thus  generated  are  collected  and  carried  into 
a  reservoir,  from  which  they  are  sucked  by  an  exhaust  fan,  and  are 
thence  forced  through  piping  and  large  flexible  hose  to  the  apartment 
to  be  fumigated. 

The  sulphur-furnace  in  use  at  the  Louisiana  Quarantine  Station 
is  the  same  in  general  principle,  with  the  addition  that  the  air  sup- 
plied to  the  burning  sulphur  is  aspirated  from  the  hold  of  the  vessel, 
and  then  forced  into  the  furnace. 

Disinfeciion  hy  Germicidal  Solutions. — The  apparatus  for  the 
use  of  the  disinfecting  solutions  consist  of  a  tank  or  tanks  elevated 
above  the  level  of  the  floor  of  the  wharf  to  a  sufficient  height  to  force 
the  solution  through  a  hose  and  nozzle  to  the  parts  of  the  ship  to  be 
reached.  The  tank  is  to  be  filled  by  a  steam-pump,  and  the  solution 
is  easily  made  by  surmounting  the  tank  with  a  keg  perforated  by 
numerous  holes,  in  which  keg  the  powdered  bichloride  is  to  be  put, 
and  the  water  for  filling  the  tank  pumped  over  it. 

It  is  a  much  better  plan  to  have  the  bichloride  solution  distrib- 
uted by  means  of  a  special  pump  (made  of  iron  to  prevent  amalgama- 
tion), as,  with  the  pressure  of  the  pump  behind  it,  it  penetrates  much 
more  deeply  into  cracks  and  crevices  and,  in  fact,  knocks  the  dirt  and 
filth  out  of  them. 

5  and  6.  Hospitals. — The  propriety  of  having  separate  hospitals 
for  contagious  and  non-contagious  diseases  is  so  obvious  that  it  need 
not  be  dwelt  on  here,  and  the  necessity  of  a  separate  establishment 
for  suspects,  until  the  nature  of  their  complaint  can  be  positively 


DOMESTIC  QUARANTINE.  498 

made  out,  is  patent  and  only  in  accord  with  expediency  and  the  ordi- 
nary instincts  of  humanity. 

7.  Barracks. — Barracks  for  the  detention  of  suspects  are  not 
an  essential  part  of  the  equipment  of  every  quarantine  station,  but 
are  a  necessity  only  at  such  stations  as  are  situated  at  the  great  ports 
of  entry,  which  are  the  ports  of  arrival  of  the  vast  hordes  of  immi- 
grants who  seek  our  shores.  Barracks  are  an  indispensable  adjunct 
in  the  management  of  ship-loads  of  immigrants  suspected  of  being 
infected  with  cholera,  typhus  fever,  and  small-pox,  and  would  be 
required  in  the  case  of  yellow  fever  but  for  the  fact  that  there  is 
little  or  no  immigration  from  the  yellow-fever  zone. 

The  barracks  should  be  commodious,  substantial,  and  yet  of  sim- 
ple and  inexpensive  construction.  They  should  be  well  ventilated 
and  so  arranged  that  every  part  of  the  building  is  under  constant 
surveillance,  and  so  subdivided  that  the  inmates  are  divided  into 
small  groups  and  intercourse  between  the  groups  prevented.  The 
immigration  laws  require  that  the  immigrants  shall  be  listed  and  ar- 
ranged in  groups  of  thirty,  and  it  would  be  well  that  this  number 
be  preserved  as  the  unit  for  segregation.  The  barracks  should  be  fur- 
nished with  bunks,  arranged  in  tiers  one  above  the  other,  and  fur- 
nished with  bedding  of  a  simple  and  inexpensive  character. 

Clothing  of  a  simple  but  sufficient  kind,  and  capable  of  easy 
laundering,  should  be  provided  in  sufficient  quantity  to  furnish  each 
inmate  of  the  barracks  with  a  change  while  his  or  her  own  personal 
effects  are  undergoing  the  process  of  disinfection.  Attached  to  the 
barracks  there  should  be  a  kitchen,  thoroughly  equipped  with  all  the 
facilities  for  furnishing  hot  food  of  a  simple  character  for  the  num- 
ber of  inmates  provided  for  by  the  barracks.  Dining-rooms  should 
be  arranged,  and  special  care  should  be  taken  to  prevent  the  carrying 
of  any  food  into  the  barracks.  It  is  perhaps  needless  to  say  that,  in 
the  barracks,  the  sexes  should  be  separated,  and  the  better  arrange- 
ment is  to  have  two  buildings — one  for  men  and  one  for  women  and 
children. 

Latrines. — Latrines  of  ample  size  should  be  provided,  and  should 
be  so  arranged  that  all  dejecta  may  be  received  into  metallic  vessels 
containing  a  germicidal  solution  of  acknowledged  potency;  or,  if  the 
dejecta  are  to  be  received  into  a  sewer,  there  should  be  some  provision 
made  for  their  complete  disinfection  prior  to  their  discharge  into  the 
sea  or  a  cess-pool. 

8.  Bath-house. — Bathing  facilities  are  an  important  part  of  the 
equipment  of  a  quarantine  station  designed  for  the  handling  of  large 


494  TEXT-BOOK  OF  HYGIENE. 

numbers  of  suspects.  The  best  form  of  bath  for  the  purpose  is  the 
shower-  or  rain-bath,  it  being  more  easily  managed,  more  expeditious, 
and  probably  more  efficacious  than  the  tub-bath.  The  bath-house 
should  be  provided  with  a  room  for  disrobing,  from  which  the  sus- 
pects will  pass  into  the  bathing-stalls  proper,  and  there  receive  a  bath 
the  temperature  of  which  is  under  the  sole  control  of  the  bath- 
attendant.  From  the  bath  the  suspect  will  pass  into  a  robing-room, 
where  he  will  be  given  a  suit  of  sterile  clothing,  while  the  clothing 
which  was  removed  in  the  disrobing-room  is  carried  by  proper  attend- 
ants to  the  disinfecting  apparatus,  there  to  be  rendered  safe  by  ster- 
ilization. 

9.  Water-supply. — An  abundant  supply  of  pure  water  is  not  only 
a  desideratum,  but  a  prime  necessity,  at  all  quarantine  stations  where 
it  is  designed  to  accommodate  cholera  suspects.  It  would  be  desir- 
able to  provide  a  supply  of  twenty  gallons  per  capita  per  day,  and  no 
arrangement  will  probably  give  such  good  results  as  the  sinking  of 
an  artesian  well,  if  the  nature  of  the  soil  and  the  geological  formation 
permit.  If  it  is  impracticable  to  sink  such  a  well,  the  next  best  plan 
would  be  to  arrange  for  the  distillation  or  sterilization,  by  boiling, 
of  a  sufficient  quantity  of  water  for  drinking  purposes. 

10.  Crematory. — A  crematory  is  a  desirable  part  of  the  equip- 
ment of  every  quarantine  station,  as  it  admits  of  no  argument  that 
cremation  is  the  best  possible  method  of  disposing  of  the  bodies  of 
those  dead  of  contagious  or  infectious  disease.  In  addition,  it  would 
be  desirable  that  all  garbage  and  waste  about  a  quarantine  station  be 
incinerated  to  prevent  the  possibility  of  infection, 

11  and  12. — Detailed  description  of  quarters  for  medical  officers 
and  of  laundry  is  unnecessary. 

Having  thus  considered  the  necessities  and  the  desiderata  in 
the  equipment  of  a  quarantine  station,  it  is  now  proper  to  consider 
the  regulations  governing  them,  and  for  this  purpose  are  here  ap- 
pended the  regulations  prepared  by  the  Supervising  Surgeon-General 
of  the  Marine-Hospital  Service,  and  promulgated  by  the  Secretary  of 
the  Treasury  on  April  26,  1894.  These  regulations  are  to  be  con- 
sidered a  minimum  for  the  stations  under  municipal  and  State  con- 
trol, some  of  which  have  additional  requirements: — 


DOMESTIC  QUARANTINE.  495 

Domestic  Regulations. 

QUABAJSTTINE   REGULATIONS    TO    BE    OBSERVED    AT    PORTS    AND    ON    THE    FRON- 
TIERS OF  THE  United  States  and  its  Possessions  and  Dependencies. 

Preamble. 

52.  At  or  convenient  to  the  principal  ports,  quarantine  stations 
should  be  equipped  with  all  appliances  for  the  inspection  and  treat- 
ment of  vessels,  their  passengers,  crews,  and  cargoes. 

53.  For  ail  ports  where  such  provisions  have  not  been  made,  in- 
spection stations  should  be  maintained.  An  inspection  service  should 
be  maintained  for  every  port  throughout  the  year. 

54.  At  a  fully  equipped  quarantine  station  there  should  be  ade- 
quate provision  for  boarding  and  inspection,  apparatus  for  mechan- 
ical cleansing  of  vessels,  apparatus  for  disinfection  by  steam,  by  sul- 
phur, by  formaldehyde,  by  disinfecting  solutions,  or  any  other  method 
prescribed  in  these  regulations;  also  a  clinical  laboratory,  hospitals 
for  contagious  and  doubtful  cases,  a  steam  laundry,  detention  bar- 
racks for  suspects,  bathing  facilities,  a  crematory,  a  sufficient  supply 
of  good  water,  and  a  proper  system  for  the  disposal  of  sewage. 

55.  The  personnel  of  quarantine  stations  in  the  yellow-fever  zone 
and  on  fruiters  and  other  vessels  of  regular  lines  bound  for  southern 
ports  from  ports  where  yellow  fever  prevails  should  be  immune  to 
yellow  fever. 

56.  At  quarantine  stations  all  articles  liable  to  convey  infection 
should  be  handled  only  by  the  employees  of  said  station  unless  the 
services  of  the  crew  of  the  vessel  in  quarantine  are  indispensable. 

57.  Vessels  having  been  treated  at  national  quarantine  stations 
that  are  located  a  considerable  distance  from  the  ports  of  entry  of  said 
vessels  may  be  inspected  by  the  local  quarantine  officer,  and  if  for  any 
sanitary  reason  it  is  considered  inadvisable  to  admit  the  vessel,  he 
should  report  the  facts  immediately  by  telegraph,  when  possible,  to 
the  Surgeon-General  of  the  Public  Health  and  Marine-Hospital  Serv- 
ice, detaining  the  vessel  pending  his  action.. 

58.  The  following  regulations  are  the  required  minimum  stand- 
ard and  do  not  prevent  the  addition  of  such  other  rules  as,  for  special 
reasons,  may  be  legally  made  by  State  or  local  authorities. 

Inspection. 

59.  Every  vessel  siil>ject  to  quarantine  inspection,  entering  a 
port  of  the  United  States,  its  possessions  or  dependencies,  shall  be 


496  TEXT-BOOK  OF  HYGIENE. 

considered  in  quarantine  until  given  free  pratique.  Such  vessel  shall 
fly  a  3'ellow  flag  at  the  foremast  head  from  sunrise  to  sunset,  and  shall 
observe   all  the  other  requirements   of  vessels   actuall}^  quarantined. 

60.  Vessels  arriving  at  ports  of  the  United  States  under  the 
following  conditions  shall  be  inspected  by  a  quarantine  officer  prior 
to  entry: — 

(a)  All  vessels  from  foreign  ports  except  those  enumerated  in 
paragraph  4. 

(b)  Any  vessel  with  sickness  on  board. 

(c)  Vessels  from  domestic  ports  where  cholera,  plague,  or  yel- 
low fever  prevails,  or  where  small-pox  or  typhus  fever  prevails  in 
epidemic  form. 

(d)  Vessels  from  ports  suspected  of  infection  with  yellow  fever, 
having  entered  a  port  north  of  the  southern  boundary  of  Maryland 
without  disinfection,  shall  be  subjected  to  a  second  inspection  before 
entering  any  ports  south  of  said  latitude  during  the  quarantine  season 
of  such  port. 

61.  The  inspections  of  vessels  required  by  these  regulations  shall 
be  made  between  sunrise  and  simset,  except  in  case  of  vessels  in  dis- 
tress. 

62.  In  making  the  inspection  of  a  vessel,  the  bill  of  health  and 
clinical  record  of  all  cases  treated  during  the  voyage,  crew  and  pas- 
sengers' lists  and  manifests,  and  when  necessary,  the  ship's  log  shall 
be  examined.  The  crew  and  passengers  shall  be  mustered  and  exam- 
ined and  compared  with  the  lists  and  manifests  and  any  discrepancies 
investigated.  The  clinical  thermometer  should  be  used  in  the  exam- 
ination of  the  personnel  of  vessels  under  suspicion.  When  a  freight 
manifest  shows  that  rags  and  other  articles  requiring  disinfection 
under  these  regulations  are  carried  by  the  vessel,  a  certificate  of  dis- 
infection, signed  by  a  United  States  consul  or  a  medical  officer  of  the 
United  States,  shall  be  exhibited  and  compared  with  same.  If  no 
certificate  of  disinfection  is  produced  the  collector  of  customs  at  the 
port  of  entry  shall  be  notified  of  same  by  the  quarantine  officer.  The 
collector  of  customs  shall  then  hold  such  consignment  in  a  designated 
place  separate  from  other  freight  pending  the  arrival  of  the  certificate 
of  disinfection;  and  in  the  event  of  its  nonarrival,  the  articles  shall 
be  disinfected  as  hereinbefore  prescribed,  or  shall  be  returned  by  the 
common  carrier  conveying  the  same. 

63.  The  medical  officers  of  the  United  States,  duly  clothed  with 
authority  to  act  as  quarantine  officers  at  any  port  or  place  within  the 
United  States,  and  when  performing  the  said  duties,  are  hereby  au- 


DOMESTIC  QUARANTINE.  497 

thorized  to  take  declarations  and  administer  oaths  in  matters  per- 
taining to  the  administration  of  the  quarantine  laws  and  regulations 
of  the  United  States.     (Act  of  March  2,  1901,  sec.  12.) 

64.  No  person,  except  the  quarantine  officer,  his  employees, 
United  States  customs  officers,  pilots,  or  other  persons  authorized  by 
the  quarantine  officer,  shall  be  permitted  to  board  any  vessel  subject 
to  quarantine  inspection  until  after  the  vessel  has  been  inspected  by 
the  quarantine  officer  and  granted  free  pratique,  and  all  such  persons 
so  boarding  such  vessel  shall,  in  the  discretion  of  the  quarantine  offi- 
cer, be  subject  to  the  sanie  restrictions  as  the  personnel  of  the  vessel. 

65.  Towboats  or  any  other  vessels  having  had  communication 
Avith  vessels  subject  to  inspection  shall  themselves  be  subject  to  in- 
spection. 

66.  After  arrival  at  a  quarantine  station  of  a  vessel  carrying 
immigrants  and  upon  which  there  has  appeared  during  the  last  voy- 
age a  case  of  cholera,  small-pox,  typhus  fever,  or  plague,  and  after 
quarantine  measures  provided  by  regulations  of  the  Treasury  Depart- 
ment have  been  enforced  and  the  vessel  given  free  pratique,  it  is 
hereby  ordered  that  notification  of  the  above-mentioned  facts  be  trans- 
mitted by  the  quarantine  officer  to  the  Commissioner  of  Immigration 
at  the  port  of  arrival,  who  shall  be  requested  to  transmit,  by  mail  or 
telegraph,  to  the  State  health  authorities  of  the  several  States  to 
which  immigrants  from  said  vessel  are  destined,  the  date  of  departure, 
route,  number  of  immigrants,  and  the  point  of  destination  in  the 
respective  States  of  the  immigrants  from  said  vessel,  together  with 
the  statement  that  said  immigrants  are  from  a  vessel  which  has  been 
subject  to  quarantine  by  reason  of  infectious  disease,  naming  the  dis- 
ease. This  information  is  furnished  to  State  health  officers  for  the 
purpose  of  enabling  them  to  maintain  such  surveillance  over  the 
arriving  immigrants  as  they  may  deem  necessary. 

67.  When  a  vessel  arriving  at  quarantine  has  on  board  any  of  the 
communicable  but  non-quarantinable  diseases,  the  quarantine  officer 
shall  promptly  inform  the  local  health  authorities  of  the  existence  of 
such  disease  aboard  and  shall  make  every  effort  to  furnish  such  notifi- 
cation in  ample  time,  if  possible,  to  permit  of  the  case  being  seen  by 
the  local  authorities  before  discharge  from  the  vessel. 

Quarantine. 

68.  Vessels  arriving  under  the  following  conditions  shall  be 
placed  in  quarantine: — 


498  TEXT-BOOK  OF  HYGIENE. 

(a)  With  quarantinable  disease  on  board  or  having  had  such 
disease  on  board  during  the  voyage. 

(b)  Any  vessel  which  the  quarantine  officer  considers  infected. 

(c)  If  arriving  at  a  port  south  of  the  southern  boundary  of 
Maryland  in  the  season  of  close  quarantine,  May  1  to  November  1, 
directly  or  via  a  northern  port,  from  a  tropical  American  port,  unless 
said  port  is  known  to  be  free  from  yellow  fever. 

(d)  In  the  case  of  vessels  arriving  at  a  northern  port  without 
sickness  on  board  from  ports  where  yellow  fever  prevails,  the  per- 
sonnel shall  be  detained  under  observation  at  quarantine  to  complete 
five  days  from  the  port  of  departure. 

(e)  Towboats  and  other  vessels  having  had  communication  with 
vessels  subject  to  quarantine  shall  themselves  be  quarantined  if  they 
have  been  exposed  to  infection. 

69.  Vessels  arriving  under  the  following  conditions  need  not  be 
subject  to  quarantine: — 

A.  Vessels  from  yellow  fever  ports  bound  for  ports  in  the  United 
States  north  of  the  southern  boundary  of  Maryland,  with  good  sani- 
tary condition  and  history,  having  had  no  sickness  on  board  at  ports 
of  departure,  enroute,  or  on  arrival,  provided  they  have  been  five  days 
from  last  infected  or  suspected  port. 

B.  Vessels  engaged  in  the  fruit  trade  may  he  admitted  to  entry 
without  detention,  provided  that  they  have  complied  in  all  respects 
with  the  special  rules  and  regulations  made  by  the  Secretary  of  the 
Treasury  with  regard  to  vessels  engaged  in  said  trade. 

General  Requirements  at  Quarantine. 

70.  Pilots  will  be  detained  in  quarantine  a  sufficient  time  to 
cover  the  period  of  incubation  of  the  disease  for  which  the  vessel 
is  quarantined,  if,  in  the  opinion  of  the  quarantine  officer,  such  pilots 
have  been  exposed  to  infection.  The  dunnage  of  pilots  shall  be  dis- 
infected when  necessary. 

71.  No  direct  communication  shall  be  allowed  between  any  vcFsel 
in  quarantine  and  any  person  or  place  outside,  and  no  communication 
whatever  between  quarantine  or  any  vessel  in  quaratine  and  any 
person  or  place  outside  except  under  the  supervision  of  the  quaran- 
tine officer. 

72.  Street  cleanings,  street  sweepings,  or  any  other  form  of  bal- 
last containing  organic  refuse  must  be  discharged  at  the  quarantine 
station. 


DOMESTIC  QUARANTINE.  499 

73.  No  presumably  infected  ballast  shall  be  allowed  to  leave  the 
quarantine  station  until  disinfected. 

74.  After  a  vessel  has  been  rendered  free  from  infection,  it  may 
be  furnished  vi^ith  a  fresh  crew  and  released  from  quarantine,  while 
all  or  part  of  the  personnel  are  detained.  Under  these  circumstances 
the  quarantine  officer  must  exercise  the  greatest  care  that  the  vessel 
shall  not  become  reinfected,  especially  by  contact  with  persons  in 
quarantine  or  infected  objects. 

75.  Vessels  detained  at  any  national  quarantine  will  be  subject 
to  such  additional  rules  and  regulations  as  may  be  promulgated  from 
time  to  time  by  the  Surgeon-General. 

76.  The  form  of  certificate  which  shall  be  issued  to  a  vessel  by 
the  health  officer  when  he  releases  her  from  quarantine  shall  be  pre- 
scribed by  the  Surgeon-General  of  the  Public  Health  and  Marine- 
Hospital  Service,  and  shall  embody  the  statement  that  the  vessel  has 
in  all  respects  complied  with  the  quarantine  regulations  prescribed 
by  the  Secretary  of  the  Treasury,  and  that  in  the  opinion  of  the 
quarantine  officer  she  will  not  convey  quarantinable  disease,  and  that 
said  vessel  is  granted  free  pratique  to  enter  her  port  of  destination, 
the  name  of  which  is  to  be  embodied  in  the  blank. 

77.  The  persons  detained  shall  be  inspected  by  the  physician 
twice  daily,  and  be  under  his  constant  surveillance,  and  no  intercourse 
will  be  allowed  between  different  groups  while  in  quarantine. 

78.  No  articles  from  an  infected  vessel  shall  be  carried  into  the 
place  of  detention  until  disinfected. 

79.  Cleanliness  of  quarters  and  of  person  shall  be  enjoined  and 
daily  enforced.  Disinfection  shall  be  practiced  where  there  is  any 
possibility  of  infection. 

80.  The  water  and  food  supply  shall  be  strictly  guarded  to  pre- 
vent any  contamination. 

81.  Water-closets,  urinals,  privies,  or  troughs  shall  be  provided, 
and  their  contents  disinfected  before  they  are  discharged. 

83.  In  any  group  in  which  communicable  disease  appears,  the 
sick  will  be  immediately  isolated  in  hospital,  and  the  remaining  per- 
sons in  the  group  and  their  effects  appropriately  treated  and  then 
removed  to  other  quarters  if  possible,  and  the  compartments  disin- 
fected. 

83,  Communication  between  the  physician  and  attendants  of  the 
hospital  and  those  detained  in  other  parts  of  the  quarantine  station 
shall  be  reduced  to  a  minimum. 

84.  No  convalescent  shall  be  discharged  from  quarantine  until 


500  TEXT-BOOK  OF  HYGIENE. 

after  a  sufficient  time  has  elapsed  to  insure  his  freedom  from  infec- 
tion, and  this  is  to  be  determined  by  bacteriological  examination 
where  possible. 

85.  No  other  person  shall  be  discharged  from  quarantine  until 
the  period  of  incubation  of  the  disease  has  elapsed  since  the  last 
exposure  to  infection. 

86.  The  body  of  no  person  dead  of  quarantinable  disease  shall 
be  allowed  to  pass  through  quarantine  until  one  year  has  elapsed  since 
death.  Such  bodies  must  l)e  transported  in  hermetically  sealed  cof- 
fins, the  outsides  of  which  have  been  carefully  disinfected. 

In  the  case  of  the  bodies  of  such  persons  as  may  have  died  on 
the  voyage  or  upon  arrival  at  quarantine,  cremation  should  be  re- 
sorted to  if  practicable  and  consented  to ;  if  not,  the  body  should  be 
wrapped  without  preliminary  washing  in  a  sheet  saturated  with  a  solu- 
tion of  bichloride  of  mercury  1 :500  and  buried,  surrounded  by  caustic 
lime. 

87.  The  quarantine  officer  shall  report  to  the  Secretary  of  the 
Treasury  all  violations  of  the  quarantine  laws.  He  should  also  report 
the  facts  in  the  case  to  the  Surgeon-General  of  the  Public  Health  and 
Marine-Hospital  Service. 

88.  The  quarantine  officer  shall  report  to  the  collector  of  cus- 
toms any  vessel  which  arrives  without  the  bill  of  health  hereinbefore 
prescribed. 

89.  All  vessels  requiring  inspection  under  these  regulations  must 
present  to  the  collector  of  customs  at  the  port  of  entry  the  quaran- 
tine certificate  above  prescribed. 

Special  Regulations  on  Account  of  Cholera. 

90.  For  the  purpose  of  these  regulations  five  days  shall  be  con- 
sidered as  the  period  of  incubation  of  cholera. 

91.  If  the  vessel  carry  persons  from  cholera-infected  ports  or 
places,  a  bacteriological  examination  should  be  made  of  any  cases  of 
diarrhea  to  exclude  cholera  before  granting  free  pratique. 

92.  If  cholera  has  appeared  on  board,  remove  all  passengers  from 
the  vessel  and  all  of  the  crew,  save  those  necessary  to  care  for  her; 
place  the  sick  in  hospital.  Carefully  isolate  those  especially  suspected 
and  segregate  the  remainder  in  small  groups.  ISTo  communication 
should  be  held  between  these  groups.  Those  believed  to  be  especially 
capable  of  conveying  infection  must  not  enter  the  place  of  detention 
until  they  are  bathed  and  furnished  with  non-infected  clothing;    nor 


DOMESTIC  QUARANTINE.  501 

shall  any  material  capable  of  conveying  infection  be  taken  into  the 
place  of  detention,  especially  food  and  water. 

93.  Water  and  food  supply  must  be  strictly  guarded  to  prevent 
contamination  and  issued  to  each  group  separately. 

94.  Food  of  a  simple  character,  sufficient  in  quantity,  thoroughly 
cooked,  shall  be  issued  to  those  detained  in  quarantine.  No  fruit  or 
uncooked  vegetables  shall  be  permitted. 

95.  The  greatest  care  must  be  exercised  to  prevent  the  spread 
of  the  infection  through  the  agency  of  flies  or  other  insects. 

96.  The  dejecta  from  all  persons  in  quarantine  on  account  of 
cholera  shall  be  disinfected  before  final  disposition. 

97.  The  water  supply  of  the  vessel,  if  suspected  of  infection,  must 
be  disinfected  and  then  changed  without  delay;  the  casks  or  tanks 
disinfected  and  after  thorough  rinsing  refilled  from  a  source  of  un- 
doubted purity,  or  the  water  furnished  must  have  been  recently  boiled. 

98.  The  baggage  or  effects  of  passengers  and  crew  that  may  have 
been  exposed  to  infection  must  be  disinfected. 

99.  Articles  of  cargo  which  have  been  exposed  to  infection  and 
are  liable  to  convey  the  same  must  be  disinfected. 

100.  Living  apartments  and  their  contents  and  such  other  por- 
tions of  the  vessel  as  have  been  exposed  to  infection  must  be  dis- 
infected. 

101.  Water  ballast  taken  on  at  a  cholera-infected  port  should 
be  discharged  at  sea,  or  if  discharged  in  fresh  or  brackish  water  must 
previously  be  disinfected.  Vessels  arriving  with  water  ballast  pre- 
sumably infected  must  return  to  sea  under  guard  in  order  to  dis- 
charge such  ballast.  If  practicable  the  tanks  should  be  disinfected 
before  being  flushed,  and  refilled  with  sea  water. 

Special  Regulations  on  Account  of  Yelloiv  Fever. 

102.  For  the  purpose  of  these  regulations,  five  days  shall  be  con- 
sidered as  the  period  of  incubation  of  yellow  fever. 

103.  Where  practicable  remove  the  sick  to  hospital;  remove  and 
isolate  all  persons  not  required  for  care  of  vessel. 

104.  For  the  destruction  of  mosquitoes  there  shall  be  a  prelimi- 
nary and  simuHaneous  fumigation  of  all  parts  of  the  vessel  by  sul- 
phur dioxide  gas.  In  cal)ins  containing  articles  liable  to  damage  by 
sulphur  dioxide,  pyrethrum  powder  may  be  burned  instead. 

105.  If,  from  the  disposition  of  the  cargo  or  any  other  reason, 
the  previous  fumigation  is  deemed  not  to  have  been  effective,  a  com- 


502  TEXT-BOOK  OF  HYGIENE. 

plete  fumigation  is  now  to  be  done^  simultaneously,  of  the  whole 
vessel.  Measures  are  in  all  cases  to  be  taken  to  destroy  larvge  of  mos- 
quitoes aboard. 

106.  The  personnel  of  the  vessel  shall  be  detained  five  days  from 
completion  of  disinfection,  or  if  they  have  been  removed  before  dis- 
infection of  the  vessel,  their  detention  shall  begin  from  last  possible 
exposure  to  infection. 

If  cases  of  yellow  fever  have  occurred  aboard,  the  time  of  deten- 
tion at  stations  south  of  the  southern  boundary  of  Maryland  must  be 
jextended  to  six  days.- 

107.  If  the  vessel  has  in  all  respects  complied  with  the  quaran- 
tine regulations  to  be  observed  at  foreign  ports  in  such  cases,  and  has 
been  disinfected  under  the  supervision  of  an  accredited  medical  officer 
of  the  United  States  at  the  port  of  departure,  she  may,  upon  arrival 
at  her  port  of  destination  in  the  United  States,  with  good  sanitary 
history  and  in  good  condition,  be  subject  to  the  following  treat- 
ment : — 

(a)  If  arriving  in  five  days  or  less,  she  may  be  admitted  to 
pratique  without  disinfection  or  further  detention  than  is  necessary 
to  complete  the  five  days. 

(&)  If  arriving  after  five  days  and  within  ten  days,  she  may  be 
immediately  fumigated  and  admitted  without  detention. 

(c)  If  arriving  after  a  longer  voyage  than  ten  days,  she  shall  be 
treated  as  if  she  had  not  been  subjected  to  any  previous  treatment.''^ 

108.  Passenger  traffic  without  detention  may  be  allowed  during 
the  close  quarantine  season,  May  1  to  November  1,  from  ports  in- 
fected with  yellow  fever  to  ports  in  the  United  States  south  of  the 
southern  boundary  of  Maryland  under  the  following  conditions : — 

(a)  Vessels  to  be  of  iron  or  the  best  class  of  wooden  vessels,  and 
to  be  cleaned  immediately  prior  to  taking  on  passengers.  The  officer 
issuing  the  bill  of  health  to  these  vessels  shall  withhold  the  same  if 
the  vessel  is  not  in  first-class  sanitary  condition  and  complying  in 
every  respect  with-  the  conditions  stated  in  this  paragraph. 

(6)  The  vessel  must  lie  at  approved  moorings  in  the  open  har- 
bor; must  not  approach  the  wharves,  nor  must  the  crew  be  allowed 
ashore  at  the  port  of  departure.     Every  possible  precaution  must  be 


-  The  period  of  incubation  of  yellow  fever  is  not  rarely  over  five  days. 

'  If  the  vessel  should  have  been  in  transit  for  a  considerable  number  of 
days,  it  is  obvious  that  a  case  of  yellow  fever  may  have  occurred  and  re- 
covered, leaving  the  vessel  infected,  and  not  affording  any  opportunity  to  the 
quarantine  officer  to  determine   same. 


DOMESTIC  QUAllANTINE.  503 

taken  to  prevent  the  ingress  of  mosquitoes,  and  to  provide  for  the 
destruction  of  these  should  they  find  ingress. 

(c)  All  passengers  and  crew  must  be  immune  to  yellow  fever 
and  so  certified  by  the  United  States  medical  officer.* 

109.  The  disinfection  of  baggage  for  yellow  fever  is  not  required, 
but  baggage  destined  directly  or  indirectly  for  any  State  shall  be  dis- . 
infected  at  the  request  of  the  health  officer  of  said  State.  All  bag- 
gage shall  be  inspected  and  the  absence  of  mosquitoes  definitely 
proven.  The  presence  of  any  mosquitoes,  regarding  the  infection  of 
which  the  quarantine  officer  has  doubts,  shall  be  sufficient  grounds 
for  such  further  measures  as  the  quarantine  officer  may  deem  Justi- 
fiable. 

Special  Regulations  on  Account  of  Small-pox. 

110.  For  the  purpose  of  these  regulations,  fourteen  days  shall 
be  considered  as  the  period  of  incubation  of  small-pox. 

111.  On  all  vessels  arriving  with  small-pox  on  board,  or  having 
had  small-pox  on  board  during  the  voyage,  any  of  the  personnel  who 
have  been  exposed  to  the  infection  of  the  disease  must  be  vaccinated 
or  detained  in  quarantine  not  less  than  fourteen  days,  unless  they 
show  satisfactory  evidence  of  recent  successful  vaccination  or  of  hav- 
ing had  small-pox. 

112.  Vessels  arriving  with  small-pox  on  board  which  has  been 
properly  isolated  and  other  sufficient  precautions  taken  to  prevent  the 
spread  of  the  disease  need  not  be  quarantined  further  than  the  re- 
moval of  the  sick,  the  disinfection  of  all  compartments,  baggage,  and 
objects  that  have  been  exposed  to  the  liability  of  infection,  and  such 
vaccination  of  the  personnel  as  required  in  paragraph  111. 

113.  On  vessels  arriving  with  small-pox  on  board  and  where  the 
proper  isolation  and  other  precautions  have  not  been  taken,  all  those 
whom  the  quarantine  officer  believes  to  have  been  exposed  to  the 
infection  will  be  detained  unless  they  have  had  small-pox  or  unless 
they  show  satisfactory  signs  of  having  been  properly  vaccinated  within 
one  year. 

114.  Living  compartments  and  their  contents  or  any  other  part 
of  the  vessel  exposed  to  the  infection  must  be  disinfected. 

115.  The  baggage  and  effects  of  passengers  and  crew  that  have 
been  exposed  to  the  infection  must  be  disinfected. 


^The  pvidfinco  of  immunity  which  may  be  acoepted  by  the  sanitary 
inspector  is:  First,  proof  of  previous  attack  of  yellow  fever;  second,  proof 
of  continued  residence  in  an  endemic  focus  of  yellow  fever  for  ten  years. 


504  TEXT-BOOK  OF  HYGIENE. 

Special  Regulations  on  Account  of  Typhus  Fever. 

116.  For  the  purpose  of  these  regulations  twelve  days  shall  be 
considered  as  the  period  of  incubation  of  tjqohus  fever. 

117.  Vessels  in  otherwise  good  sanitary  condition,  but  having 
typhus  fever  on  board  which  has  been  properly  isolated,  need  not  be 
quarantined  further  than  the  removal  of  the  sick,  and  disinfection 
of  the  compartments  and  their  contents  exposed  to  infection. 

118.  If  the  case  has  not  been  isolated,  or  the  disease  has  spread 
on  board  from  person  to  person,  the  vessel  will  be  quarantined,  the 
sick  removed,  and  those  who  have  been  exposed  to  the  infection 
detained  under  observation. 

119.  Vessels  in  bad  sanitary  condition,  on  which  the  disease  has 
appeared,  will  be  quarantined  until  thoroughly  cleansed  and  disin- 
fected throughout ;  the  sick  will  be  cared  for  at  isolated  hospitals,  and 
those  exposed  to  the  infection  detained  under  observation. 

120.  The  baggage  and  effects  of  passengers  and  crew  that  have 
been  exposed  to  the  infection  must  be  disinfected. 

121.  Living  compartments  and  their  contents,  or  any  other  parts 
of  the  vessel  exposed  to  the  infection,  must  be  disinfected. 

Special  Regulations  on  Account  of  Leprosy. 

122.  Vessels  arriving  at  quarantine  with  leprosy  on  board  shall 
not  be  granted  pratique  until  the  leper  with  his  or  her  baggage  has 
been  removed  from  the  vessel  to  the  quarantine  station. 

123.  No  alien  leper  shall  be  landed. 

124.  If  the  leper  is  an  alien  passenger  and  the  vessel  is  from  a 
foreign  port,  action  will  be  taken  as  provided  by  the  immigration  law's 
and  regulations  of  the  United  States.  And  to  this  end  the  case  shall 
be  certified  as  a  leper  and  reported  to  the  nearest  commissioner  of 
immigration. 

125.  If  the  leper  is  an  alien  and  a  member  of  the  crew  and  the 
vessel  is  from  a  foreign  port,  said  leper  shall  be  detained  at  the  quar- 
antine at  the  vessel's  expense  until  taken  aboard  by  the  same  vessel 
when  outward  bound.  Such  case  of  leprosy  should  be  promptly  re- 
ported to  the  collector  of  customs  at  the  port  of  arrival  of  the  vessel, 
and  the  collector  shall  exact  a  bond  from  the  vessel  for  the  reship- 
ment  of  the  said  alien  leper  upon  the  departure  of  the  vessel. 


DOMESTIC  QUARANTINE.  505 

Special  Regulations  on  Account  of  Plague. 

126,  For  the  purpose  of  these  regulations  seven  days  shall  be  con- 
sidered as  the  period  of  incubation  of  plague. 

137.  In  those  actually  exposed  to  the  infection  of  plague  the 
administration  of  antipest  serum  is  regarded  as  a  valuable  prophyl- 
actic measure;  for  the  prevention  of  the  introduction  of  plague  into 
a  community  liable  to  the  introduction  of  plague  through  commercial 
intercourse,  immunization  by  Haffkine's  prophylactic  is  to  be  rec- 
ommended. 

128.  Vessels  infected  with  plague,  or  suspected  of  such  infec- 
tion, should  be  anchored  at  a  sufficient  distance  from  the  shore  or 
other  vessels,  to  prevent  the  escape  of  rats  by  swimming. 

129.  In  inspecting  vessels  from  plague-infected  ports,  or  vessels 
with  plague  on  board  at  port  of  departure,  en  route  or  on  arrival,  the 
personnel  of  the  vessel  should  be  examined  with  special  reference  to 
the  glandular  regions,  cervical,  axillary,  and  inguinal,  and  for  such 
examination  as  much  clothing  should  be  removed  as  may  interfere 
with  the  thoroughness  of  the  process.  When  possible,  females  should 
be  examined  by  female  inspectors.^ 

130.  In  the  inspection  of  vessels  for  plague,  special  attention 
must  be  directed  to  the  discovery  of  cases  of  a  mild  type  or  of  the 
pneumonic  form  of  the  disease.  Suspected  or  doubtful  cases  should  be 
subjected  to  bacteriological  examination  before  the  vessel  is  released. 

131.  On  all  plague-infected  vessels,  any  of  the  personnel  of  such 
vessels  who,  in  the  opinion  of  the  quarantine  officer,  are  infected  or 
have  been  exposed  to  infection,  shall  be  bathed  and  body  clothing  and 
hand  baggage  disinfected. 

132.  Nothing  shall  be  thrown  overboard  from  the  vessel,  not  even 
deck  sweepings.  Such  material  shall  be  burned  in  the  furnaces  of  a 
steamer,  or  in  a  place  specially  designated,  but  not  in  the  galley. 

133.  Special  precautions  must  be  taken  against  rats,  mice,  ants, 
flies,  fleas,  and  other  animals,  on  account  of  the  danger  of  the  infec- 
tion of  the  disease  being  spread  through  their  agency. 

134.  As  soon  as  practicable,  there  shall  be  a  preliminary  disin- 
fection with  sulphur  dioxide  for  the  purpose  of  killing  rats  and  ver- 
min, before  further  disinfecting  processes  are  applied  to  the  vessel 
and  her  cargo.     The  killing  of  any  escaping  rats  shall  be  provided 


''T'he  examination  herein  provided  being  an  exceedingly  delicate  matter, 
the  greatest  possible  care  is  to  be  used  by  the  quarantine  officer  to  avoid  any 
grounds  for  complaint  of  indecent  exposure,  and  more  particularly  vi^ith 
regard  to  females. 


506  TEXT-BOOK  OF  HYGIENE. 

for  by  a  water  guard  in  small  boats,  and  no  person  with  abrasions  or 
open  sores  should  be  employed  in  the  handling  of  the  vessel  or  her 
cargo. 

135.  The  vessel  shall  be  submitted  to  a  simultaneous  disinfection 
in  all  parts  with  sulphur  dioxide  to  insure  the  destruction  of  rats  and 
vermin.  The  rats  shall  be  subsequently  gathered  and  burned,  due 
precautions  being  taken  not  to  touch  them  with  the  bare  hands,  and 
the  places  where  found  disinfected  with  a  germicidal  solution;  and 
the  quarantine  officer  shall  assure  himself  that  the  vessel  is  free  of 
rats  and  vermin  before  granting  free  pratique. 

136.  Disinfection  of  vessels  for  plague  shall  be  as  follows: — 
With  cargo :     After  twelve  hours'  exposure  to  sulphur  dioxide, 

the  upper  4  to  6  foot  layer  of  cargo  may  be  removed  and  placed  on 
lighters  exposed  to  the  sun.  This  process  of  disinfection  by  night, 
and  removal  of  successive  layers  of  cargo  by  day,  to  be  continued  until 
hold  is  empty. 

137.  Vessels  without  cargo  shall  be  disinfected  by  sulphur  diox- 
ide, followed  by  germicidal  solutions,  in  accordance  with  the  general 
regulations  for  disinfection,  paragraphs  156  to  185. 

Canadian  and  Mexican  Frontier's. 

138.  When  practicable,  alien  immigrants  arriving  at  Canadian 
or  Mexican  ports,  destined  for  the  United  States,  shall  be  inspected 
at  the  Canadian  or  Mexican  port  of  arrival  by  the  United  States 
consular  or  medical  officer,  and  be  subjected  to  the  same  sanitary 
restrictions  as  are  called  for  by  the  rules  and  regulations  governing 
United  States  ports. 

139.  Inspection  cards  will  be  issued  by  the  consular  or  United 
States  medical  officer  at  the  Canadian  or  Mexican  port  of  arrival  to 
all  such  alien  immigrants,  and  labels  affixed  to  their  baggage,  as  is 
required  at  foreign  ports  in  the  case  of  those  coming  direct  to  any 
port  of  the  United  States. 

140.  If  any  person  be  found  suffering  from  a  quarantinable  dis- 
ease, or  be  presumably  infected,  he  shall  be  denied  entry  or  shall  be 
kept  under  quarantine  observation  so  long  as  danger  of  conveying 
the  infection  exists. 

141.  Any  baggage  or  other  effects  believed  to  be  infected  shall 
be  refused  entry  unless  disinfected  in  accordance  with  these  regula- 
tions. 

142.  Persons  coming  from  localities  where  cholera  is  prevailing 


DOMESTIC  QUARANTINE.  507 

shall  not  be  allowed  entry  until  after  five  days  have  elapsed  since  last 
presumable  exposure  to  infection,  and  their  baggage  disinfected. 

143.  During  the  quarantine  season  persons  not  positively  identi- 
fied as  immune  to  yellow  fever,  coming  from  places  where  yellow  fever 
prevails,  will  not  be  permitted  to  enter  until  they  have  been  away 
from  said  localities  five  full  daj^s. 

144.  Persons  coming  from  localities  where  small-pox  is  prevail- 
ing shall  not  be  allowed  entry  without  vaccination,  unless  they  are 
protected  by  a  previous  attack  of  the  disease  or  a  recent  successful 
vaccination.  The  baggage  of  persons  from  such  localities  shall  be 
disinfected. 

145.  Persons  coming  from  localities  where  typhus  fever  prevails 
in  epidemic  form  shaU  not  be  allowed  entry  until  twelve  days  have 
elapsed  since  their  last  possible  exposure  to  infection  and  the  disin- 
fection of  their  baggage. 

146.  Persons  coming  from  localities  where  plague  is  prevailing 
shall  not  be  allowed  entry  until  seven  days  have  elapsed  since  their 
last  possible  exposure  to  infection  and  the  disinfection  of  their  bag- 
gage. 

147.  No  common  carrier  which  is  infected,  or  suspected  of  being 
infected,  shall  be  allowed  to  enter  the  United  States  until  after  such 
measures  have  been  taken  as  will  render  it  safe. 

148.  Articles  of  merchandise,  personal  effects,  etc.,  which  are 
presumably  infected,  shall  not  be  allowed  entry  into  the  United  States 
until  after  disinfection. 

149.  Eags  gathered  and  baled  in  Canada,  accompanied  by  affi- 
davits that  the  ports  or  places  where  collected  or  handled  Avere  free 
from  quarantinable  disease  for  thirty  days  prior  to  shipment,  may  be 
admitted  to  entry;  but  rags  from  foreign  ports  shipped  through  Can- 
ada shall  not  be  admitted  to  entry  unless  they  are  accompanied  by  a 
certificate  of  a  United  States  consul  or  medical  officer  of  the  United 
States  that  they  have  been  disinfected,  or  until  after  they  have  been 
unbaled  and  disinfected  at  the  port  of  arrival. 

150.  AYhere  not  otherwise  specifically  stated,  the  rules  and  regu- 
lations for  maritime  quarantine  shall  be  applied  at  stations  on  the 
Canadian  and  Mexican  frontiers;  and  the  methods  of  disinfection 
shall  be  those  prescribed  in  these  regulations. 

SprcinI  Rrf/iiJaiions  Relating  to  Naval  Vessels. 

151.  Vessels  of  Ihe  U.  S.  Navy  may  be  granted  the  hereinafter 
stated  exemptions  from  quarantine  regulations,  but  are  subject  to 


508  TEXT-BOOK  OF  HYGIENE. 

quarantine  inspection  upon  arrival  at  a  port  of  the  United  States. 

152.  The  certificates  of  the  medical  officers  of  the  U.  S.  Navy  as 
to  the  sanitary  history  and  condition  of  the  vessel  and  its  personnel 
may  be  accepted  for  naval  vessels  by  the  quarantine  officer  boarding 
the  vessel  in  lieu  of  an  actual  inspection. 

153.  Vessels  of  the  U.  S.  Navy  having  entered  the  harbors  of 
infected  ports,  but  having  held  no  communication  which  is  liable  to 
convey  infection,  may  be  exempted  from  the  disinfection  and  deten- 
tion imposed  on  merchant  vessels  fom  such  ports. 

Inspection  of  State  and  Local  Quarantine. 

154.  In  the  performance  of  the  duties  imposed  upon  him  by  the 
act  of  February  15,  1893,  the  Surgeon-General  of  the  Public  Health 
and  Marine-Hospital  Service  shall,  from  time  to  time,  personally  or 
through  a  duly  detailed  officer  of  the  Public  Health  and  Marine- 
Hospital  Service,  inspect  the  maritime  quarantines  of  the  United 
States,  State  and  local,  as  well  as  national,  for  the  purpose  of  ascer- 
taining whether  the  quarantine  regulations  prescribed  by  the  Secre- 
tary of  the  Treasury  have  been  or  are  being  complied  with.  The 
Surgeon-General,  or  the  officer  detailed  by  him  as  inspector,  shall,  at 
his  discretion,  visit  any  incoming  vessel  or  any  vessel  detained  in 
quarantine,  and  all  portions  of  the  quarantine  establishment,  for  the 
above-named  purpose,  and  with  a  view  to  certifying,  if  need  be,  that 
the  regulations  have  been  or  are  being  enforced. 

155.  The  Surgeon-General  of  the  Public  Health  and  Marine- 
Hospital  Service  is  authorized,  when  in  his  discretion  such  action  is 
necessary  in  the  interest  of  the  public  health,  to  remand,  by  direction 
of  the  Secretary  of  the  Treasury,  any  vessel  to  the  nearest  national. 
State,  or  local  quarantine  station  provided  with  proper  facilities  for 
handling  infected  vessels. 

Disinfectants  Authorized  by  these  Eegulations  and  the 
Proper  Methods  of  Generatincx  and  Using  Same. 

Physical  Disin.fectants. 

156.  Burning.     Of  unquestioned  efficiency,  but  seldom  required. 

157.  Boiling.  Very  efficient  and  of  wide  range  of  applicability. 
The  articles  must  be  wholly  immersed  for  not  less  than  thirty  min- 
utes in  water  actually  boiling  (100°  C).  The  addition  of  1  per  cent, 
of  carbonate  of  soda  renders  the  process  applicable  to  polished  steel, 
cutting  instruments,  or  tools. 


DOMESTIC  QUARANTINE.  509 

158.  Steam: — 

(a)  Flowing  steam  (not  under  pressure).  Flowing  steam  (not 
under  pressure)  when  applied  under  suitable  conditions  is  an  efficient 
disinfecting  agent.  The  exposure  must  be  continued  thirty  minutes 
after  the  temperature  has  reached  100°  C. 

(h)  Steam  under  pressure  without  vacuum.  Steam  under  pres- 
sure will  sterilize,  provided  that  the  process  is  continued  twenty  min- 
utes after  the  pressure  reaches  15  pounds  per  square  inch.  The  air 
must  be  expelled  from  the  apparatus  at  the  beginning  of  the  process. 
If  impracticable  to  obtain  the  designated  pressure,  a  longer  exposure 
will  accomplish  the  same  result. 

(c)  Steam  under  pressure  with  vacuum.  Steam  in  a  special 
apparatus  with  vacuum  attachment  is  the  best  method  of  applying 
steam  under  pressure,  the  object  of  the  vacuum  apparatus  being  to 
expel  the  air  and  to  promote  the  penetration  of  the  steam.  The 
process  is  to  be  continued  for  twenty  minutes  after  the  pressure 
reaches  10  pounds  to  the  square  inch. 

Gaseous  Disinfectants. 

159.  Sulphur  dioxide.  Sulphur  dioxide  is  efficient,  but  requires 
the  presence  of  moisture.  It  is  only  a  surface  disinfectant,  and  is 
lacking  in  penetrating  properties.  An  atmosphere  containing  4.5 
per  cent,  can  be  obtained  by  burning  5  pounds  of  sulphur  per  1000 
cubic  feet  of  space.  This  amount  would  require  the  evaporation  or 
volatilization  of  about  1  pint  of  water.  Under  these  conditions  the 
time  of  exposure  should  be  not  less  than  twenty-four  hours  for  bac- 
terial infections.  A  shorter  time  will  suffice  for  fumigation  necessary 
to  kill  mosquitoes  and  other  vermin. 

160.  The  sulphur  may  be  burned  in  shallow  iron  pots  (Dutch 
ovens)  containing  not  more  than  30  pounds  of  sulphur  for  each  pot, 
and  the  pots  should  stand  in  vessels  of  water.  The  sulphur  pots 
should  be  elevated  from  the  bottom  of  the  compartment  to  be  disin- 
fected in  order  to  obtain  the  maximum  possible  percentage  of  com- 
bustion of  sulphur.  The  sulphur  should  be  in  a  state  of  fine  division, 
and  ignition  is  best  accomplished  by  alcohol ;  special  care  to  be  taken 
with  this  method  to  prevent  damage  to  cargo  of  vessel  by  fire;  or 
the  sulphur  may  be  burned  in  a  special  furnace,  the  sulphur  dioxide 
being  distributed  by  a  power  fan.  This  method  is  peculiarly  appli- 
cable to  cargo  vessels. 

K;i.  TJqiifficd  sulphur  dioxide  may  be  used  for  disinfection  in 


510  TEXT-BOOK  OF  HYGIENE. 

place  of  sulphur  dioxide  generated  as  above,  it  being  borne  in  mind 
that  this  process  will  require  3  pounds  of  the  liquefied  gas  for  each 
pound  of  sulphur  as  indicated  in  the  above  paragraphs. 

163.  Sulphur  dioxide  is  especially  applicable  to  the  holds  of 
vessels,  or  to  freight  cars  and  apartments  that  may  be  tightly  closed 
and  which  do  not  contain  objects  injured  b}^  the  gas.  Sulphur  dioxide 
bleaches  fabrics  or  material  dyed  with  vegetable  or  aniline  dyes.  It 
destroys  linen  or  cotton  goods  by  rotting  the  fiber  through  the  agency 
of  the  acids  formed.  It  injures  most  metals.  It  is  promptly  destruc- 
tive to  all  forms  of  animal  life.  This  property  renders  it  a  valuable 
agent  for  the  extermination  of  rats,  insects,  and  other  vermin. 

Formaldehyde  Gas. 

1G3.  Formaldehyde  gas  is  effective  if  applied  by  one  of  the 
methods  given  below.  Formaldehyde  gas  has  the  advantage  as  a 
disinfectant  that  it  does  not  injure  fabrics  or  most  colors.  It  is  not 
poisonous  to  the  higher  forms  of  animal  life.  It  fails  to  kill  vermin 
such  as  rats,  mice,  roaches,  bedbugs,  etc.  The  method  is  not  appli- 
cable to  the  holds  of  large  vessels.  Formaldehyde  is  applicable  to 
the  disinfection  of  rooms,  clothing,  and  fabrics,  but  should  not  be 
depended  upon  for  bedding,  upholstered  furniture,  and  the  like,  when 
deep  penetration  is  required." 

164.  Many  formaldehyde  solutions  do  not  contain  40  per  cent. 
of  formaldehyde,  and  all  are  apt  to  deteriorate  with  time.  It  is  there- 
fore necessary  to  use  a  quantity  in  excess  of  the  amount  prescribed 
in  these  regulations,  unless  the  solution  has  been  recently  analyzed. 

165.  The  following  methods  of  evolving  the  gas  may  be  used : — 
(a)   Autoclave  under  pressure,  3  to  13  hours'  exposure. 

(h)   Lamp  or  generator,  6  to  18  hours'  exposure. 

(c)  Spraying,  13  to  34  hours'  exposure. 

(d)  Formaldehyde  and  dry  heat  in  partial  vacuum,  1  hour's 
exposure. 

166.  The  minimum  number  of  hours'  exposure  as  given  above 
applies  to  empty  rooms  of  tight  construction  containing  smooth,  hard 
surfaces;  the  maximum  number  of  hours'  exposure  applying  in  all 
cases  to  textiles  and  other  articles  of  a  similar  kind  requiring  more 
or  less  penetration. 

167.  Autoclave  under  pressure.     This  method  has  considerable 


"It   should  be  noted   that  formaldehyde  disinfection  is  more  efficient  in 
warm,  moist  or  still  weather  than  in  cold,  dry  or  windy  weather. 


DOMESTIC  QUARANTINE.  511 

penetrating  power  when  applied  as  detailed  below.  Rooms  or  apart- 
ments need  no  special  preparation  beyond  the  ordinary  closing  of 
doors  and  windows.  Pasting,  caulking,  or  chinking  of  ordinary  cracks 
and  crevices  is  not  necessary.  The  doors  of  lockers  and  closets  and 
the  drawers  of  bureaus  should  be  opened.  In  this  apparatus  use  for- 
malin (40  per  cent.),  with  the  addition  of  a  neutral  salt,  such  as 
calcium  chloride  (20  per  cent.).  The  gas  must  be  evolved  under  a 
pressure  not  less  than  45  pounds.  After  the  gas  is  separated  from  its 
watery  solution  the  pressure  may  be  allowed  to  fall  and  steam  pro- 
jected into  the  compartment  to  supply  the  necessary  moisture.  Use 
not  less  than  10  ounces  of  formalin  per  1000  cubic  feet,  and  keep  the 
room  closed  for  three  to  twelve  hours  after  the  completion  of  the 
process.  For  large  rooms  the  gas  must  be  introduced  at  several 
points  as  far  apart  as  possible.  It  is  applicable  to  the  disinfection 
of  clothing  and  fabrics  suspended  loosely  in  such  a  manner  that  every 
article  is  freely  accessible  to  the  gas  from  all  directions. 

168.  Lamp  or  generator.  This  method  requires  an  apparatus 
producing  formaldehyde  by  a  partial  oxidation  of  wood  alcohol,  and 
in  using  it  the  room  or  apartment  should  be  rendered  tight  as  prac- 
ticable. Oxidize  24  ounces  of  wood  alcohol  per  1000  cubic  feet,  and 
keep  the  room  closed  for  six  to  eighteen  hours,  in  accordance  with 
the  provisions  of  paragraph  165.  This  method  leaves  little  or  no  odor. 
When  applied  to  clothing  and  textiles,  the  articles  should  be  sus- 
pended in  a  tight  room  and  so  disposed  as  to  permit  free  access  of  the 
gas.  (See  also  Par.  166.)  The  wood  alcohol  should  be  of  95  per 
cent,  strength,  and  should  not  contain  more  than  5  per  cent,  of  ace- 
tone. 

169.  Spraying.  The  formalin  (40  per  cent.)  should  be  sprayed 
on  sheets  suspended  in  the  room  in  such  a  manner  that  the  solution 
remains  in  small  drops  on  the  sheet.  Spray  not  less  than  10  ounces 
of  formalin  (40  per  cent.)  for  each  1000  cubic  feet.  Used  in  this 
way  a  sheet  will  hold  about  5  ounces  without  dripping  or  the  drops 
running  together.  The  room  must  be  very  tightly  sealed  in  disin- 
fecting with  this  process,  and  kept  closed  not  less  than  twelve  hours. 
The  method  is  limited  to  rooms  or  apartments  not  exceeding  2000 
cubic  feet.  The  formalin  may  also  be  sprayed  upon  the  walls,  floors, 
and  objects  in  the  rooms. 

170.  Formaldehyde  witli  dry  heat  in  partial  vacuum.  This 
method  has  superior  penetrating  powers  and  is  specially  applicable 
to  clothing  and  baggage.  The  requirements  of  this  method  are  (1) 
dry  heat  of  60°   C.  sustained    for  one  hour;     (2)    a  vacuum  of  15 


512  TEXT-BOOK  OF  HYGIENE. 

inches;  (3)  formaldehyde  evolved  from  a  mixture  of  formalin  with 
a  neutral  salt,  in  an  autoclave  under  pressure,  using  not  less  than 
30  ounces  of  formalin  (40  per  cent.)  for  1000  cubic  feet;  and  (4)  a 
total  exposure,  under  these  combined  conditions,  of  one  hour. 

171.  The  stated  times  of  exposure  to  sulphur  dioxide  and  for- 
maldehyde are  sufficient  to  destroy  bacterial  infection  due  to  non- 
spore-bearing  organisms,  providing  that  the  infection  is  present  on 
the  surface.  If  the  room  is  of  peculiar  construction,  so  as  to  impede 
the  diffusion  of  the  gas,  or  if  the  room  is  a  dirty  one,  or  if  on  account 
of  any  other  condition  rendering  the  germicidal  action  of  the  gas 
more  difficult,  the  time  of  exposure  should  be  proportionately  in- 
creased, or  supplanted  by  other  methods. 

Chemical  Solutions. 

172.  Bichloride  of  mercury.  Bichloride  of  mercury  is  a  disin- 
fectant of  undoubted  potency  and  wide  range  of  applicability.  It 
cannot  be  depended  upon  to  penetrate  substances  in  the  presence  of 
albuminous  matter.  It  should  be  used  in  solutions  of  1  to  1000.  The 
solubility  of  bichloride  of  mercury  may  be  increased  by  using  sea 
water  for  solution,  or  by  adding  2  parts  per  1000  of  sodium  or  ammo- 
nium chloride  to  the  water  employed. 

173.  Carbolic  acid.  Carbolic  acid  in  the  strength  of  5  per  cent, 
(see  par.  51)  may  be  substituted  for  the  bichloride  of  mercury,  and 
should  be  employed  in  the  disinfection  of  the  cabins  and  living  apart- 
ments of  ships  to  obviate  injurious  action  on  polished  metals,  bright 
Avork,  etc. 

174.  Formalin.  Formalin  containing  40  per  cent,  of  formalde- 
hyde may  be  used  in  a  5-per  cent,  solution  as  a  substitute  for  bichlo- 
ride of  mercury  or  carbolic  acid,  and  is  ureful  for  the  disinfection  of 
surfaces,  dejecta,  fabrics,  and  a  great  variety  of  objects,  owing  to  its 
non-injurious  character. 

Application  of  Disinfectants  in  Quarantine  Work. 

175.  Hold  of  iron  vessel,  empty,  shall  be  disinfected  by  either: — • 
(a)    Sulphur   dioxide  generated   by  burning   sulphur   5   pounds 

per  1000  cubic  feet  of  air  space,  or  liberated  from  10  pounds  of  liquid 
sulphur  dioxide,  sufficient  moisture  being  present  in  both  cases;  time 
of  exposure,  twenty-four  hours.     (See  par.  159.) 

(h)   Washing  with  a  solution  of  bichloride  of  mercury,  1:1000. 

176.  Holds  of  wooden  vessels,  empty,  shall  be  disinfected  by: — 


DOMESTIC  QUARANTINE.  513 

(fl)    Sulphur  dioxide  in  the  manner  prescribed  above,  followed  by 
(&)   Washing  with  a  solution  of  bichloride  of  mercury. 

177.  In  the  case  of  all  vessels,  both  iron  and  wooden,  when 
treated  for  yellow  fever  or  plague  infection,  the  first  process  shall  be 
a  preliminary  fumigation  by  sulphur  dioxide  in  the  manner  pre- 
viously stated  in  paragraph  159-160,  in  order  to  insure  the  destruc- 
tion of  mosquitoes,  rats,  and  other  vermin. 

178.  Holds  of  cargo  vessels,  when  cargo  cannot  be  removed,  shall 
be  disinfected  in  so  far  as  possible  by  sulphur  dioxide  not  less  than  4 
per  cent,  per  vo]ume  strength,  and  where  possible  this  should  be  gen- 
erated from  a  furnace  to  minimize  danger  of  fire  in  cargo. 

179.  Living  apartments,  cabins,  and  forecastles  of  vessels  shall 
be  disinfected  by  one  or  more  of  the  following  methods: — 

(a)  Sulphur  dioxide,  the  destructive  action  of  the  gas  on  prop- 
erty being  borne  in  mind. 

(b)  Formaldehyde  gas. 

(c)  Washing  with  solution  of  bichloride  of  mercury,  1 :1000  or 
5-per-cent.  solution  of  formalin,  or  5-per-cent.  solution  of  carbolic 
acid,  preference  being  given  to  carbolic  acid  for  application  to  pol- 
ished woods,  bright  metals,  and  other  objects  injured  by  metallic  salts. 

The  forecastle,  steerage,  and  other  living  apartments  in  bad  sani- 
tary condition  must  be  disinfected  by  method  (a)  followed  by  method 
(c). 

180.  Mattresses,  pillows,  and  heavy  fabrics  are  to  be  disinfected 
by  :— 

(a)   Boiling. 

(&)   Flowing  steam;   {.e.^  steam  not  under  pressure. 

(c)  Steam  under  pressure. 

(d)  Steam  in  a  special  apparatus  with  vacimm  attachment. 

181.  Clothing,  fabrics,  textiles,  curtains,  hangings,  etc.,  may  be 
treated  by  either  of  the  above  methods  from  (a)  to  (d)  inclusive,  as 
circumstances  may  demand,  or  by  formaldehyde  gas  or  sulphur  dioxide 
where  the  article  is  of  a  character  which  will  not  be  damaged  by  sul- 
phur dioxide. 

182.  Articles  injured  by  steam,  such  as  leather,  furs,  skins,  rubber, 
trunks,  valises,  hats  and  caps,  bound  books,  silks,  and  fine  woolens 
should  not  l)e  disinfected  by  steam.  Such  articles  should  be  disin- 
fected by  formaldehyde  gas  or  by  any  of  the  agents  allowed  in  these 
regulations  which  may  be  applicable  thereto.  Those  which  will  be 
injured  by  wetting  should  be  disinfected  by  a  gaseous  agent. 

183.  Clothing,  textiles,  and  baggage,  clean  and  in  good  condition, 

33 


514  TEXT-BOOK  OF  HYGIENE. 

but  suspected  of  infection,  can  be  efficiently  and  least  injuriously  dis- 
infected by  formaldehyde  gas,  generated  by  one  of  the  methods  pre- 
scribed in  paragraph  165 — (a),  (h),  0T(d). 

184.  Textiles  which  are  soiled  with  the  discharge  of  the  sick  or 
presumably  are  deeply  infected,  must  be  disinfected  by: — 

(a)   Boiling. 

(&)    Steam. 

(c)   Immersion  in  one  of  the  germicidal  solutions. 

185.  Cooking  and  eating  utensils  are  alwaj's  to  be  disinfected  by 
immersion  in  boiling  water  or  by  steam. 

It  is  the  intention  of  the  act  of  February  15,  1893,  under  which 
these  regulations  were  framed,  to  have  them  act  uniformly  and  with- 
out discrimination  against  any  place,  and  at  the  same  time  to  not 
interfere  with  the  operation  of  any  additional  regulations  imposed  by 
State  or  local  autho^it3^ 

MANAGEMENT  OF  A  QUARANTINE  STATION. 

Inspection. — Upon  the  arrival  of  a  vessel  at  a  quarantine  station, 
during  the  active  quarantine  season,  she  should  be  boarded  without 
delay,  and  the  following  general  routine  followed,  with  such  modi- 
fications as  may  be  demanded  by  the  local  conditions  or  dictated  by 
the  experience  of  the  quarantine  officer.  In  the  event  of  the  arrival 
of  several  vessels  at  the  same  time,  they  should,  as  a  rule,  be  boarded 
as  nearly  as  possible  in  the  order  of  their  arrival,  the  rule  of  "first 
come,  first  served"  being  observed;  though  it  may  be  remarked  that, 
in  the  event  of  the  arrival,  at  nearly  the  same  time,  of  a  vessel  carry- 
ing passengers  and  one  carrying  cargo  only,  there  will  usuaHy  be  little 
opposition  on  the  part  of  ship-masters  if  the  passenger-ship  is  in- 
spected first.  Arrived  on  board,  it  is  well  to  demand  the  immediate 
attendance  of  the  master,  not  only  from  the  fact  that  all  information 
must  be  sought  from  him,  but  to  impress  all  concerned  with  the  fact 
that  the  authority  of  the  boarding-officer  is,  for  the  time,  absolute. 
The  master  should  then  be  required  to  produce  for  inspection  his  bills 
of  health,  the  ship's  manifest,  and  the  crew-  and  passenger-lists,  if  the 
ship  carry  passengers.  These  should  be  carefully  scrutinized,  the 
number  of  crew  and  passengers  being  noted  or  borne  in  mind,  and 
note  being  made  of  an}''  articles  of  cargo  that  come  within  the  pro- 
scription of  the  regulations.  All  special  consular  certificates  bearing 
on  doubtful  articles  of  cargo  had  better  be  looked  into  at  this  time. 
A  careful  inspection  of  the  ship  should  now  follow,  particular  atten- 
tion being  paid   to   the   condition   of   the   living-apartments   of   the 


TREATMENT  OF  YELLOW-FEVER  VESSELS.  515 

officers  and  crew,  as  their  condition  of  cleanliness  or  the  reverse  some- 
times forms  an  important  index  to  the  cleanliness  of  the  whole  ship. 
The  hatches  should  be  removed,  and  such  portions  of  the  cargo  as 
come  directly  under  them  be  subjected  to  scrutiny.  If  the  vessel  is 
in  ballast,  the  hold  should  be  entered,  explored,  and  mental  note  made 
of  the  condition  of  the  ship's  inner  planking  or  skin,  whether  dry  and 
sound  or  rotten  and  damp.  If  possible,  a  limber  plank  should  be 
lifted,  and  the  condition  of  the  bilges  noted.  In  the  comparatively 
inaccessible  places  fore  and  aft  there  will  likely  be  found  deposits  of 
trash  and  filth,  and  the  chain-lockers  should  be  carefully  examined 
to  see  whether  the  cables  have  been  properly  washed  prior  to  stowing. 
The  inspection  of  the  ship  proper  completed,  the  inspection  of  per- 
sons should  be  entered  into. 

Every  person  borne  upon  the  ship's  papers  as  passenger  or  mem- 
ber of  the  crew  should  be  personally  seen  by  the  boarding-officer  or 
his  assistant,  and  no  excuse  whatever  should  be  taken  for  an  absence 
from  this  muster.  In  vessels  suspected  of  the  infection  of  plague  or 
yellow  fever,  the  temperature  of  passengers  and  crew  should  be  taken 
to  assist  in  the  detection  of  cases  of  these  diseases  in  the  early  stages, 
and  to  this  end  every  quarantine  station  should  be  supplied  with  a 
liberal  number  of  good  clinical  thermometers.  Take  nothing  for 
granted,  and  compel  the  master  to  explain  any  discrepancies  between 
the  lists  and  the  actual  number  presenting  themselves  for  examina- 
tion. The  decision  must  now  be  reached  whether  the  vessel  goes  free 
under  the  regulations  or  is  to  be  detained  in  quarantine.  If  the 
former,  the  certificate  of  inspection  is  filled  out,  and  the  master 
notified  that  he  is  at  liberty  to  proceed.  If  the  latter,  the  vessel  is 
directed  to  a  suitable  anchorage,  and  the  yellow  quarantine  flag  is 
hoisted  at  the  foremast-head.  Quarantine  procedures  proper  now 
begin,  and  much  depends  on  the  nature  of  the  disease  quarantined 
against;  the  nature  and  condition  of  the  ship,  whether  light,  in  bal- 
last, or  loaded.  If  there  are  passengers  on  board,  these  are  landed, 
bathed,  and  assigned  to  quarters  in  the  barracks.  The  vessel  is  laid 
alongside  of  the  wharf  and  the  disinfecting  processes  prescribed  by 
the  regulations  entered  upon. 

TREATMENT  OF   YELLOW=FEVER  VESSELS. 

A  vessel  infected  with  yellow  fever  is  one  which  has  on  board 
actual  cases  of  the  disease,  or  which  contains  mosquitoes  of  the  genus 
Stegornyia  fasciaia  which  have  had  opportunities  of  biting  persons 
infected  with  yellow  fever,  either  at  the  port  of  departure  or  upon 


516  TEXT-BOOK  OF  HYGIENE. 

the  voyage.  If  there  are  Stegomyia  fasciata  on  board  a  ship  and  a 
case  has  occurred  on  board  within  three  or  four  days,  these  mosquitoes 
must  be  regarded  as  infected,  unless  the  utmost  care  has  been  taken 
to  screen  the  patients  from  their  attacks.  If  the  ship  is  from  a 
yellow-fever  port,  that  is  to  say,  where  yellow  fever  actually  prevails, 
and  presents  Stegomyia  fasciata  on  board,  these  Stegomjdse  are  pre- 
sumably infected,  and  if  as  much  as  twelve  days  have  elapsed  on  the 
voyage,  are  capable  of  conveying  yellow  fever  to  non-immunes.  The 
treatment  of  yellow  fever  vessels,  therefore,  is  limited  to  efforts 
directed  to  kill  mosquitoes  in  the  living  apartments  and  in  the  holds 
of  the  vessel  and  to  preventing  their  breeding  in  places  favorable  to 
their  development.  Various  means  can  be  adopted  to  this  end.  The 
burning  of  sulphur — two  pounds  per  1000  cubic  feet,  time  of  ex- 
posure twelve  hours — is  efficacious.  If  it  is  apprehended  that  the 
sulphur  fumes  will  be  injurious  or  prejudicial  to  clothing,  hang- 
ings, bright  work,  polished  metal,  etc.,  pyrethrum  powder  may 
be  substituted  for  the  sulphur,  burning  one  pound  per  1000  cubic 
foot,  the  time  of  exposure  to  be  about  three  hours.  Pyrethrum  pow- 
der is  not  an  insecticide;  it  simply  stupefies  the  insects,  and  at  tlie 
expiration  of  this  time  the  room  or  apartment  should  be  cautiously 
opened  and  the  stupefied  mosquitoes  swept  up  and  burned.  The  use 
of  pyrethrum,  therefore,  would  generally  be  limited  to  the  living 
apartments  and  especially  to  the  cabins  of  ships;  sulphur  is  safer, 
more  efficacious,  and  easier  of  application  in  the  forecastles  and  holds. 
Should  there  be  patients  sick  with  yellow  fever  upon  the  vessel 
on  the  arrival  at  quarantine,  these  should  be  at  once  removed  to  the 
infectious  hospital  if  their  condition  permits  it,  and  the  remainder 
of  the  crew  and  passengers  should  be  inspected  twice  daily  until  the 
time  of  danger,  that  is  to  say,  the  period  of  the  incubation  of  the 
disease,  five  or  six  days,  has  elapsed.  In  the  care  and  treatment  of 
these  passengers  detained  in  quarantine  on  account  of  yellow  fever, 
care  should  be  taken  to  immediately  isolate  every  febrile  case  and  to 
thoroughly  protect  it  by  mosquito  netting  or  wire  gauze  from  the 
access  of  mosquitoes  until  a  positive  diagnosis  is  arrived  at.  If  there 
are  no  mosquitoes,  or  care  is  taken  to  prevent  the  infection  of  mos- 
quitoes, there  will  be  no  spread  of  the  disease.  The  ballast  and  cargo 
of  vessels  from  yellow-fever  ports  are  only  dangerous  in  so  far  as 
they  may  harbor  infected  mosquitoes.  The  matter  can  be  summed  up 
in  the  dictum :  "A  vessel  or  a  house  infected  with  yellow  fever  is  a 
vessel  or  house  which  contains  within  its  walls  infected  mosquitoes 
of  the  genus  Stegomyia  fasciata."     (Eeed.) 


TREATMENT  OF  PLAGUE  VESSELS.  517 

TREATMENT  OF  PLAGUE  VESSELS. 

In  vessels  departing  from  a  port  where  plague  prevails,  precau- 
tions against  plague  should  be  commenced  at  the  port  of  departure. 
This  disease  has  of  late  years  been  robbed  of  much  of  its  traditional 
terror,  owing  to  the  fact  that  its  cause,  its  nature,  and  the  methods 
of  handling  it  in  epidemic  form  have  become  better  understood.  In 
the  ordinary  or  bubonic  type  of  the  disease,  there  is  little  danger  to 
be  apprehended  from  the  patient  himself.  In  the  cases  pneumonic 
in- type  from  their  inception,  or  becoming  pneumonic  as  a  secondary 
infection,  the  patient  is  dangerous,  as  the  sputum  contains  the  organ- 
ism of  the  disease. 

The  spread  of  plague  seems  to  be  generally  effected  by  means 
of  rats  or  mice,  though  insects,  such  as  fleas,  bedbugs,  ants,  etc.,  may 
also  play  a  part,  not  by  directly  conveying  the  plague  microorganism, 
but  their  bites,  irritated  by  scratching,  affording  an  avenue  of  entrance 
for  the  plague  bacillus,  which  may  be  carried  on  the  bodies  or  feet 
of  the  insects,  or  possibly  conveyed  in  their  dejecta. 

A  most  essential  precaution  in  a  port  infected  with  plague  is  to 
prevent  the  access  of  rats,  mice,  and  other  vermin  on  board  ship.  This 
is  best  accomplished  by  not  allowing  the  ship  to  approach  the  dock; 
but  if  this  is  necessary  for  the  purpose  of  loading,  the  ship  should  be 
breasted  off  five  or  six  feet  from  the  walls  of  the  dock,  and  the  lines 
and  chains  leading  ashore  should  be  protected  by  rat-guards  or  cones 
surrounding  the  lines,  their  large  open  ends  directed  toward  the 
shore.  If  these  are  impracticable,  or  not  to  be  obtained,  the  lines 
or  chains  should  be  freshly  tarred,  and,  as  the  rat  is  more  prone  to 
move  by  night  than  by  day,  the  gang-ways  or  planks  connecting  the 
ship  and  the  shore  should  be  removed  before  sunset. 

A  case  of  plague  developing  on  the  voyage  should  be  isolated,  and 
any  articles  which  may  be  soiled  or  infected  by  the  patient  should  be 
disinfected  or,  in  the  absence  of  means  for  accomplishing  this,  should 
be  destroyed. 

Careful  observations  should  be  made  upon  voyages  from  plague- 
infected  ports  to  ascertain  any  marked  sickness  or  increased  mor- 
tality among  the  rats  which  almost  always  are  found  on  shipboard. 
Experience  has  shown  that  an  outbreak  of  plague  in  man  is  almost 
invarialjly  preceded  by  an  increased  mortality  among  rats  and  mice. 

Arriving  at  a  quarantine  station,  vessels  infected  with  plague, 
or  suspecterl  of  sufh  infoctifm,  should  l)e  anchored  at  a  sufficient  dis- 
tance from  the  shore  or  from  other  vessels  to  prevent  the  escape  of 


518  TEXT-BOOK  OF  HYGIENE. 

rats  by  swimming.  The  personnel  of  the  vessel,  passengers  and  crew, 
should  be  subjected  to  a  rigid  inspection,  if  there  have  been  cases  of 
plague  during  the  voj^age,  and  this  inspection  should  be  so  conducted 
that  the  condition  of  the  glandular  regions  of  the  body,  the  subcer- 
vical,  axillary,  and  inguinal,  may  be  ascertained.  Special  attention 
should  be  directed  to  the  detection  of  mild  or  ambulant  cases  of  the 
disease,  and  any  case  of  illness  partaking  of  the  nature  of  a  severe 
bronchitis  or  of  pneumonia  should  be  the  subject  of  a  special  investi- 
gation and,  if  possible,  a  bacteriological  examination. 

On  plague-infected  vessels,  any  of  the  crew  who,  in  the  opinion 
of  the  quarantine  officer,  have  been  exposed  to  the  direct  infection  of 
plague  should  be  bathed,  and  any  of  their  belongings  supposed  to  have 
been  exposed  to  infection  should  be  disinfected.  Measures  should  be 
at  once  entered  into  to  insure  the  destruction  of  rats,  mice,  fleas,  bugs, 
and  even  flies  and  ants,  on  account  of  the  danger  of  the  spread  of 
infection  through  their  agency.  This  is  best  accomplished  by  a  simul- 
taneous disinfection  of  the  ship  by  sulphur  dioxide.  During  this 
process,  the  escape  of  rats  should  be  guarded  against,  and  any  rats 
found  escaping  should  be  killed  by  shooting  or  by  means  of  sticks  or 
other  implements.  The  rats  and  mice  killed  by  this  fumigating 
process  should  be  gathered,  and  it  is  best  not  to  handle  them  with 
the  naked  hands.  They  should  be  collected  with  gloves  and  their 
bodies  burned,  and  the  spots  upon  which  they  have  been  found  dead 
should  be  disinfected  by  actually  boiling  water  or  by  one  of  the 
germicidal  solutions,  and  the  vessel  should  not  be  considered  as  free 
from  danger  until  she  is  free  from  rats.  The  last  International 
Sanitary  Conference  of  Paris,  1903,  lent  themselves  to  the  declaration 
that  merchandise,  in  itself,  was  incapable  of  conveying  the  infection 
of  plague,  and  was  only  dangerous  when  soiled  or  contaminated  by 
plague-stricken  rats.  Should  it  be  necessary  to  disinfect  a  ship  in- 
fected with  plague  and  containing  cargo,  this  disinfection  should  be 
conducted  in  a  fractional  manner,  by  removing  a  portion  of  the  cargo 
and  exposing  it  to  sun  and  air  upon  lighters.  Sulphur  dioxide  is 
then  to  be  generated  or  introduced  into  the  holds  overnight,  and  dur- 
ing the  next  day  a  further  portion  of  the  cargo,  not  exceeding  four  to 
six  feet  in  depth,  should  be  removed.  The  holds  are  then  closed  again 
and  the  fumigation  is  repeated,  and  this  process  is  continued  until 
all  cargo  is  removed.  If  the  vessel  contains  no  cargo,  the  holds  should 
be  disinfected  by  sulphur  dioxide,  dead  rats  sought  for,  gathered,  re- 
moved, and  burned,  and  a  general  disinfection  by  means  of  germicidal 


TREATMENT  OF  CHOLERA  VESSELS.  519 

solutions  should  then  follow.  The  M'ater  supply  of  a  vessel  plays  no 
role  in  the  dissemination  of  plague. 

If  the  vessel  arriving  with  plague  on  board  has  a  large  number 
of  passengers,  these  passengers  should  be  removed,  segregated  into 
small  groups,  and  held  under  observation  for  the  period  of  the  incu- 
bation of  the  disease,  which  is  now  <:'onsidered  as  about  seven  days. 
Those  who  have  been  especially  exposed  to  the  infection  should  be 
segregated  by  themselves,  and  should  form  the  subject  of  careful 
observation  one  or  more  times  during  the  day.  Any  persons  in  these 
groups  presenting  suspicious  symptoms  of  illness  should  be  removed 
to  the  observation  hospital ;  and  if  these  cases  should  declare  them- 
selves to  be  plague  of  either  the  bubonic  or  pneumonic  type,  they 
should  be  at  once  removed  from  the  suspect  to  the  infectious  hospital. 

The  International  Sanitary  Conference  of  Paris,  1903,  recom- 
mended that  all  vessels  engaging  in  passenger  travel  should  be  pro- 
vided with  a  sufficient  quantity  of  anti-pest  serum  for  the  treatment 
of  actual  cases  of  plague  and  for  the  immunization  of  those  exposed 
to  its  infection.  This  suggestion  is  well  worthy  of  serious  consid- 
eration, as  the  serum  is  an  almost  certain  prophjdactic  and  affords 
the  only  successful  method  known  of  treating  actual  cases  of  the 
malady. 

TREATMENT   OF  CHOLERA  VESSELS. 

In  the  event  of  the  arrival  of  a  ship  actually  infected  with 
Asiatic  cholera,  or  suspected  of  such  infection,  a  much  more  difficult 
problem  confronts  the  quarantine  officer,  for  the  conditions  difEer 
widely  from  those  obtaining  in  the  case  of  the  yellow-fever  ship.  In 
a  majority  of  eases  the  cholera  ship  carries  a  large  number  of  passen- 
gers, a  great  majority  of  whom  belong  to  the  immigrant  class,  and  the 
difficulty  of  handling  these  is  largely  increased  by  the  carelessness  of 
their  personal  habits,  their  ignorance  and  disregard  of  the  first  laws 
of  personal  hygiene,  and  the  discomfort,  crowding,  and  bad  sanitary 
condition  of  their  quarters  on  board  ship.  Here  many  sources  of 
danger  must  be  looked  into,  and  it  is  almost  certain  that  a  disregard 
of  any  one  of  them  will  be  followed  by  a  terrible  retribution  in  the 
shape  of  new  outljreaks  of  the  disease. 

The  first  thing  to  be  done  in  tlic  treatment  of  a  cholera-infected 
ship  is  to  remove  her  human  freight,  and  this  should  be  done  as  rap- 
idly as  is  consistent  with  safety.  The  occupants  of  the  compartment 
of  the  ship  in  which  cholera  has  appeared  shonld  receive  our  first  and 
most  careful  attention.     They  must  be  landed  at  once,  bathed  with 


520  TEXT-BOOK  OF  HYGIENE. 

all  possible  precaution  and  thoroughness,  furnished  with  clean,  sterile 
clothing,  and  isolated  in  the  barracks  and  regarded  as  especially  dan- 
gerous. Those  actually  sick  with  the  disease  should  be  at  once  car- 
ried to  the  contagious  hospital,  and  those  sick  with  any  complaint 
whatever  isolated  in  the  suspect  hospital  pending  the  determination 
of  the  actual  nature  of  their  disease. 

The  foregoing  applies  particularly  to  the  steerage  passengers. 
The  question  of  the  treatment  of  the  cabin  and  saloon  passengers  is 
one  that  will  call  for  all  the  tact  and  ingenuity  of  the  quarantine 
officer,  and  even  then  he  will  be  liable  to  savage  criticism  and  censure 
through  the  friends  of  the  cabin  passengers  detained.  It  must  be 
remembered  that  these  passengers  are  luxuriously  lodged  and  catered 
for  with  every  delicate  attention  that  ingenuity  and  long  experience, 
sharpened  by  active  competition,  can  suggest.  On  board  ship  they 
are  most  carefully  guarded  from  intrusion  on  the  part  of  the  steerage 
passengers,  and,  in  fact,  are  as  nearly  on  a  separate  ship  as  possible. 
Is  it  always  necessary  to  subject  these  people  to  the  inconveniences 
and  possible  hardships  that  are  inseparable  from  a  detention  in  quar- 
antine barracks?  The  answer  is  that  each  case  must  be  decided  on 
its  individual  merits,  and  much  will  depend  on  the  extent  to  which 
the  ship  seems  infected,  the  seeming  source  of  the  infection,  and  the 
facilities  which  exist  on  board  ship  for  maintaining  a  sharp  line  of 
demarkation  between  the  steerage  and  saloon. 

If,  on  investigation,  it  seems  that  the  choleraic  outbreak  is  due 
to  infected  food  smuggled  on  board  by  the  emigrants,  to  infection 
probably  brought  aboard  in  the  hand-baggage  of  the  same  class  of 
passengers;  if,  in  fine,  it  would  seem  to  be  due  to  conditions  limited 
to  the  steerage,  it  might  seem  to  be  the  part  of  wisdom  to  leave  the 
cabin  passengers  in  their  luxurious  quarters  while  the  processes  of 
disinfection  and  detention  were  in  progress.  If,  on  the  contrary,  the 
infection  seems  to  be  due  to  a  polluted  ship's  water-supply;  if  there 
have  been  any  cases  of  diarrhoeal  disease  among  the  cabin  passengers ; 
if  the  infection  seem  to  be  distributed  equally  to  the  steerage  and  to 
the  saloon,  then  all  must  be  landed  alike,  and  undergo  barrack  deten- 
tion, at  least  until  the  disinfection  of  the  ship  is  thoroughly  complete. 

The  barracks  for  the  cabin  passengers  must,  of  course,  be  of  a 
different  character  from  those  provided  for  the  steerage.  They  must 
be  subdivided  into  small  rooms,  and,  instead  of  bunks,  must  be  fur- 
nished with  comfortable  cots,  bedding,  and  simple,  but  neat  and 
efficient,  toilet  facilities.  A  separate  kitchen  and  table  must  be  pro- 
vided for  this  class  of  passengers,  and  the  whole  situation  may  be 


SPECIAL  MEASURES  AGAINST  CHOLERA.  521 

summed  up  by  saying  that  the  relative  difference  on  shipboard  should 

be  preserved  on  shore  during  the  detention  in  quarantine. 

SPECIAL   MEASURES  AGAINST   CHOLERA. 

Other  features  of  quarantine  administration  are  well  expressed 
in  the  following  extract  from  the  editorial  pages  of  the  Philadelphia 
Medical  NeWB  of  October  15,  1887,  showing  the  measures  necessary 
to  extinguish  an  incipient  epidemic  of  cholera  and  to  prevent  its 
spread.     Such  measures  are  as  follow : — 

"(a)  Speedy  recognition  and  isolation  of  the  sick;  their  proper 
treatment;  absolute  and  rapid  destruction  of  the  infectious  agent  of 
the  disease,  not  only  in  the  dejecta  and  vomit,  but  also  in  clothing, 
bedding,  and  in  or  upon  whatever  else  it  finds  a  resting-place. 

"(&)  The  convalescents  should  remain  isolated  from  the  healthy 
as  long  as  their  stools  possibly  contain  any  of  the  infecting  agent; 
before  mingling  again  with  the  well  they  should  be  immersed  in  a 
disinfecting  bath,  and  afterward  be  clothed  from  the  skin  outward 
with  perfectly-clean  vestments,  which  cannot  possibly  contain  any  of 
the  infectious  material. 

"(c)  The  dead  should  be  well  wrapped  in  cloth  thoroughly  satu- 
rated in  a  solution  of  corrosive  sublimate  (1  to  500),  and,  without 
delay,  cortege,  or  lengthy  ceremonial,  buried  near  the  place  of  death  in 
a  deep  grave,  remote  as  possible  from  water  which  may,  under  any 
circumstances,  be  used  for  drinking,  washing,  culinary,  or  other  domes- 
tic purposes.  (Cremation,  of  course,  is  by  far  the  safest  way  of  dis- 
posing of  cholera  cadavers.) 

"{d)  Those  handling  the  sick  or  the  dead  should  be  careful  to 
disinfect  their  hands  and  soiled  clothing  at  once,  and  especially  before 
touching  articles  of  food,  drinking,  or  culinary  vessels. 

"(e)  In  the  case  of  maritime  quarantine,  the  well  should  be 
disembarked  and  placed  under  observation  in  quarters  spacious  enough 
to  avoid  crowding,  and  so  well  appointed  and  furnished  that  none  will 
suffer  real  hardships. 

"(/)  Once  having  reached  the  station,  those  under  observation 
should  be  separated  in  groups  of  not  more  than  twelve  to  twenty-four, 
and  the  various  groups  should,  under  no  pretext,  intermingle.  The 
quarters  for  each  group  should  afford  stationary  lavatories  and  water- 
closots  in  perfect  working  condition,  adequate  to  the  needs  of  the  in- 
dividuals constituting  the  group,  and  supplied  with  proper  means  of 
disinfection.  There  should  be  a  bed  raised  above  the  floor,  proper 
coverings,  and  a  chair  for  each  member  of  the  group,  each  person 


522  TEXT-BOOK  OF  HYGIENE. 

being  required  to  use  onl}^  his  own  bed.  There  should  be  a  common 
table  of  sufficient  size  to  seat  around  it  all  the  members  of  the  group, 
who  should  be  served  their  meals  from  a  central  kitchen,  and  with 
table-furniture  belonging  to  the  station  and  cleaned  by  the  common 
kitchen  scullions. 

"(g)  Drinking-water,  free  from  possible  contamination  and  of 
the  best  quality,  should  be  distributed  in  the  quarters  of  each  group 
as  it  is  needed,  and  in  such  a  manner  that  it  is  received  in  drinking- 
cups  only.  There  should  be  no  water-buckets  or  other  large  vessels 
in  which  handkerchiefs,  small  vestments,  children's  diapers,  etc., 
can  be  washed  by  the  members  of  any  groujD. 

"(h)  Immediately  after  being  separated  into  groups  in  their 
respective  quarters,  every  person  under  observation  should  be  obliged 
to  strip  and  get  into  a  bath  (a  disinfecting  one  is  preferable),  and 
afterward  be  clothed  with  fresh,  clean  vestments  from  the  skin  out- 
ward. Every  article  of  clothing  previously  worn  should  be  taken 
away  and  properly  disinfected. 

"(i)  Then  all  of  the  personal  effects  should  be  at  once  removed 
to  a  separate  building,  washed  (if  possible),  and  thoroughly  disin- 
fected, or  if  necessary,  destroyed.  After  disinfection  they  should  be 
temporarily  returned  to  the  members  of  groups,  when  occasion  re- 
quires a  further  change  of  clothing. 

"(A-)  Under  no  circumstances  whatever  should  washing  of  cloth- 
ing by  those  under  observation  be  permitted.  All  used  clothing  should 
be  first  thoroughly  disinfected  (by  boiling,  when  possible),  and  then 
should  be  cleansed,  the  disinfection  and  washing  being  done  by  a 
sufficiently  trained  and  absolutely  reliable  corps  of  employees  supplied 
with  adequate  appliances.    ' 

"(/)  All  those  under  observation  should  be  mustered  in  their 
own  quarters,  and  be  subjected  to  a  close  medical  inspection,  tvMle  on 
their  feet,  at  least  twice  every  day,  in  order  to  discover  and  isolate,  as 
soon  as  possible,  new  cases  which  may  develop;  and,  of  course,  the 
clothing  and  bedding  of  these  new  cases  should  be  treated  without 
delay  in  the  manner  already  mentioned.  In  the  meantime,  a  watch 
should  be  set  over  the  water-closets  for  the  purpose  of  discovering 
cases  of  diarrhoea,  and,  when  discovered,  such  cases  should  be  tem- 
porarily separated  from  the  rest.  They  should  receive  judicious 
medical  attention  at  once,  and  precautions  should  be  taken  as  if  they 
were  undoubted  but  mild  cases  of  cholera. 

"(m)  The  quarters  should  be  kept  thoroughly  clean,  and  every 
surface  upon  which   infectious  material  could  possibly  be  deposited, 


SPECIAL  MEASURES  AGAINST  CHOLERA.  523 

including  tlie  floors,  slioulcl  be  waslied  with  a  strong  disinfectant 
twice  daily,  and  oftener  when  necessary.  Evacuations  from  the  bowels 
should  be  passed  into  a  strong  disinfectant;  the  hopper  of  the  closet 
should  be  then  flushed  and  finally  drenched  with  a  quantity  of  the 
same  disinfectant. 

"(n)  Eor  the  proper  attention  to  the  sick,  there  should  be  two 
or  more  competent  and  experienced  physicians,  assisted  by  a  sufficient 
corps  of  intelligent  and  efficient  nurses,  with  hours  of  duty  so  arranged 
that  a  physician,  with  a  sufficient  number  of  nurses,  shall  be  in  con- 
stant attendance  in  the  wards  of  the  hospital. 

"(o)  For  the  prompt  recognition  and  separation  of  new  cases, 
their  temporary  medical  attention,  the  proper  treatment  of  discovered 
cases  of  diarrhoea  or  cholerine  and  of  other  maladies,  and  the  imme- 
diate correction  of  every  insanitary  practice  or  condition  by  constant, 
vigilant,  and  intelligent  supervision,  there  should  be  at  least  two  or 
more  competent  and  experienced  physicians,  with  hours  of  service  so 
arranged  that  a  physician  is  on  duty  night  and  day  among  those  under 
observation;  and  he  should  have,  subject  to  his  orders  at  any  and 
every  moment,  a  sufficient  and  efficient  corps  of  nurses  and  laborers 
to  carry  out  properly  and  promptly  his  directions. 

"(jj)  In  order  to  prevent  the  intermingling  of  the  various  groups, 
to  enforce  obedience  and  order,  and  to  make  it  absolutely  impossible 
for  the  quarantined  and  their  personal  effects  to  have  any  communi- 
cation with  the  exterior,  a  well-organized  and  sufficiently  large  police 
corps  should  patrol  the  borders  of  the  stations  and  the  buildings  day 
and  night. 

''(q)  Any  group  among  whom  there  have  developed  no  new  cases 
of  cholera  or  of  choleraic  diarrhoea,  during  the  preceding  eight  or  ten 
da3^s,  may  be  regarded  as  harmless,  and  allowed  to  leave  quarantine 
after  each  one  is  finally  immersed  in  a  disinfecting  bath  and  re- 
clothed  with  clean  garments  from  the  skin  outward,  the  garments 
removed  being  destroyed  or  thoroughly  disinfected  and  cleansed,  as 
already  indicated. 

"As  yet  no  reference  has  been  made  to  the  crew,  ship,  and  cargo. 
What  has  been  said  of  the  treatment  of  those  under  observation  ap- 
plies to  every  one  of  the  ship's  inhabitants.  The  observation,  isola- 
tion, and  cleansing  of  the  crew  and  their  effects  could  safely  be  per- 
formed aboard  fhip  if  necessary.  The  ship  should  be  thoroughly 
cleansed  and  disinfected,  particular  attention  being  given  to  the  quar- 
ters of  the  emigrants  and  crew." 

The  following  general  regulations  were  promulgated  for  the  gov- 


524  TEXT-BOOK  OF  HYGIENE. 

ernnient  of  camps  and  barracks  for  the  detention  of  cholera  suspects 
during  the  summer  of  1892  : — - 

Eegulations  foe  Cholera  Camp. 

(Prepared  in  the  Marine-Hospital  Bureau.) 

The  surgeon  in  command  of  the  quarantine  camp  to  have  abso- 
lute authority  over  the  police  and  sanitary  regulations  of  the  camp, 
and  to  see  that  they  are  obeyed. 

Camp  to  be  divided  into  two  divisions — detention  and  hospital. 
Former  for  housing  of  suspected  cases  and  well  persons  from  infected 
localities  and  the  latter  for  treatment  of  sick. 

Detention  Camp. 

1.  Persons  destined  for  this  camp  to  be  assigned  to  specific 
quarters  in  tents.  First  to  be  subjected  to  disinfecting  bath,  and 
clothed  afterward  with  fresh  vestments.  Not  to  leave  this  camp  ex- 
cept by  permission  or  order  of  surgeon  in  command. 

2.  Persons  in  detention  camp  to  be  inspected  twice  daily  or 
oftener  by  medical  officer  or  assistant,  while  standing,  to  ascertain 
any  new  cases  which  may  develop. 

3.  New  cases  of  cholera  in  detention  camp  to  be  immediately 
transferred  to  hospital  camp  for  treatment,  and  all  their  effects  dis- 
infected, as  w^ell  as  the  tent  in  which  they  may  occur. 

4.  Guards  to  patrol  detention  camp  night  and  day,  to  j)revent 
intercourse  between  the  two  divisions  of  the  camp. 

5.  Water-supply  for  entire  camp  to  be  boiled  for  drinking.  To 
be  dealt  out  to  each  person  in  cups  or  glasses  for  potable  purposes. 
May  be  acidulated  with  diluted  hydrochloric  acid  under  supervision 
of  a  medical  officer. 

6.  If  there  be  room,  the  detention  camp  to  be  segregated  into 
divisions  of  not  more  than  twenty  persons.  No  intercommunication 
should  be  permitted  between  the  groups. 

7.  All  clothing  removed  from  persons  entering  detention  camp 
to  be  subjected  to  steam  heat  (unmixed  with  air),  not  less  than  100° 
C.  (212°  F.),  for  one-half  hour,  or  boiling  for  one  hour.  Leather 
and  rubber  goods  to  be  immersed  in  3-per-cent.  carbolic-acid  solution 
until  thoroughly  saturated. 

8.  The  washing  of  clothing  not  to  be  permitted  by  the  detained 
persons  under  any  pretext.     After  above   disinfection,   all  laundry- 


SPECIAL  MEASURES  AGAINST  CHOLERA.  525 

work  to  be  then  done  by  the  force  of  employees.  The  clothing  of 
detained  suspects  should  be  kept  in  separate  building  after  disinfec- 
tion, and  re-issued  as  required  for  change. 

9.  Cleanliness  and  disinfection  of  quarters  and  person  to  be 
enjoined  and  enforced  daily.  Disinfectants  to  be  used  where  there 
is  any  possibility  of  infection. 

10.  At  the  expiration  of  five  days,  if  no  case  of  cholera  or 
choleraic  diarrhoea  has  developed  in  a  given  group  segregated  as  above, 
those  composing  the  group  may  be  discharged,  after  a  final  disinfec- 
tion of  person  and  clothing. 

11.  All  water-closets,  urinals,  privies,  or  troughs  should  be  pro- 
vided with  latrines  similar  to  those  of  the  cholera  camp,  and  means 
should  be  provided  for  their  thorough  disinfection  before  their  con- 
tents are  discharged  into  pits  of  unslacked  lime. 

12.  Food  issued  shall  be  simple,  thoroughly  cooked,  and  served 
at  stated  hours.     ISTo  fruit  permitted. 

Hospital  Camp. 

1.  Day  sick  calls  at  8  a.m.  and  4  p.m.  ;   oftener,  if  necessary. 
Night  call,  12  p.m.,  by  night  physician ;   oftener,  if  circumstances 

require. 

2.  There  shall  be  one  nurse  for  every  hospital  tent,  who  shall 
be  on  duty  in  six-hour  watches. 

Night  nurses  according  to  circumstances.  Female  nurses  for 
cases  occurring  in  that  sex. 

Nurses  should  be  instructed  in  the  necessity  of  personal  hygiene 
and  the  sources  of  infection. 

3.  Vomited  matter  and  stools  to  be  received  into  earthen  vessels, 
and  at  once  disinfected  with  3-per-cent.  solution  of  carbolic  acid  or 
1  to  500  HgClg  combined  with  2  parts  of  HCl  to  each  part  of  HgCU ; 
then  thrown  into  a  pit  of  unslacked  lime,  or  discharged  into  the  sea. 

4.  All  soiled  linen  or  clothing  that  cannot  be  disinfected  to  be 
immediately  destroyed  by  burning. 

5.  When  death  occurs,  body  to  be  immediately  buried,  swathed 
in  sheets  saturated  with  1  to  500  HgClo.  Place  of  interment  to  be 
selected  to  avoid  contamination  of  water-supply. 

6.  No  persons  having  personal  contact  with  the  sick  or  dead  shall 
leave  the  hospital  camp  without  practicing  disinfection,  as  specified 
above. 


526  TEXT-BOOK  OF  HYGIENE. 

DANGER  FROM   FLIES   IN  QUARANTINE. 

In  this  article  it  has  been  suggested  that  all  dejecta  and  vom- 
ited matters  of  cholera  patients  be  received  into  vessels  containing 
an  efficient  germicidal  solution;  and  this  is  not  onlj  for  the  reason 
that  the  said  dejecta  and  vomited  matters  ma}^  infect  an}'  one  who 
comes  into  inadvertent  contact  with  them,  but  has  an  important  bear- 
ing on  the  health  of  those  who  are  resident  in  the  neighborhood  of 
the  quarantine  station.  It  has  been  abundantly  proved  that  the  ordi- 
nary house-fly  is  capable  of  conveying  in  its  intestinal  tract,  for  a 
considerable  length  of  time,  living  and  active  cholera  spirilla.  Know- 
ing how  constantly  flies  deposit  their  ordure  on  articles  of  food,  it 
can  easily  be  seen  how  great  a  menace  to  public  health  would  be 
engendered  by  allowing  stools  containing  the  bacilli  to  remain  with- 
out instant  disinfection.  The  safer  plan  is,  therefore,  to  not  trust 
to  subsequent  disinfection,  which  might  be  overlooked  in  the  press 
of  other  matters,  but  to  receive  the  dejecta  into  the  germicidal  solu- 
lution  so  that  no  time  will  be  lost  and  no  chances  of  infection  may 
remain. 

DANGER  FROM  MOSQUITOES  IN  QUARANTINE. 

As  the  consensus  of  opinion  seems  to  be  that  the  mosquito  Stego- 
myia  fasciata  is  the  sole  means  for  the  dissemination  of  yellow  fever, 
particular  attention  should  be  paid  to  guard  patients  in  quarantine 
suffering  from  yellow  fever  from  the  attacks  of  this  insect.  Not  only 
should  the  patient  be  carefully  screened  by  mosquito  nets,  or  bv  being 
kept  in  apartments  rendered  mosquito-proof  by  wire  netting,  but 
every  effort  made  to  prevent  the  breeding  of  this  variety  of  mosquito 
in  the  neighborhood  of  a  quarantine  station.  It  is  probable  that  this 
mosquito  is  a  normal  denizen  of  every  quarantine  station  from  the 
Eio  Grande  to  the  capes  of  A-'irginia,  and  measures  for  their  pi'even- 
tion  would  consist  in  the  thorough  screening  of  all  water-containers, 
water-barrels,'  or  cisterns,  and  the  filling  in  of  all  pools  or  collections 
of  water  which  would  form  favorable  places  for  their  breeding  and 
development. 

The  Stegomyia  fasciata  is  essentially  a  house  mosquito  and  fresh 
water  is  necessary  for  its  development.  The  collections  of  water 
which  may  ordinarily  be  found  about  a  house,  as  in  wash-bowls,  wash- 
tubs,  tin  cans,  broken  bottles,  etc.,  are  particularly  favorable  places 
for  its  development,  and  these  should  be  guarded  against  at  a  quar- 
antine station  or  in  its  immediate  vicinity. 


THE  NATIONAL  QUARANTINE  SERVICE.  527 

THE  NATIONAL  QUARANTINE  SERVICE. 

The  protection  of  the  United  States  in  the  exclusion  of  quaran- 
tinable  diseases  is  provided  for  at  the  forty  national  maritime  inspec- 
tion and  disinfection  stations  located  in  the  waterways  and  ports  of 
entry  upon  the  Atlantic,  Gulf  and  Pacific  coasts.  The  principal  sta- 
tions are  as  follows : — 

Perth  Amboy,  N.  J.;  Delaware  Breakwater  Quarantine  Station, 
Lewes,  Del. ;  Eeedy  Island  Quarantine  Station,  Delaware  Eiver ;  Cape 
Charles  Quarantine  Station,  Fisherman's  Island,  Va. ;  South  Atlantic 
Quarantine  Station,  Blackbeard  Island,  Sapelo  Sound,  Georgia; 
Brunswick  Quarantine  Station,  Brunswick,  Ga. ;  Key  West  Quar- 
antine Station,  Tortugas  Islands,  Fla. ;  Gulf  Quarantine  Station, 
S'hip  Island,  Miss. ;  San  Diego  Quarantine  Station,  San  Diego,  Cali- 
fornia; San  Francisco  Quarantine  Station,  Angel  Island,  San  Fran- 
cisco Bay,  California;  and  Port  Townsend  Quarantine  Station,  Port 
Townsend,  Washington ;  Southport,  N.  C. ;  Savannah,  Ga. ;  Fer- 
nandina,  Jacksonville,  Miami,  Key  West,  Punta-Gorda,  Cedar  Keys, 
Apalachicola,  and  Pensacola,  Fla.,  and  Astoria,  Oregon. 

DESCRIPTION   OF   THE   NATIONAL   QUARANTINE   STATIONS 
ON  DELAWARE  BAY  AND  RIVER. 

It  may  prove  of  interest  to  briefly  describe  a  national  quaran- 
tine station,  and  no  better  example  can  be  found  than  the  stations 
at  Delaware  Breakwater  and  at  Eeedy  Island,  Delaware  Eiver.  These 
stations,  while  in  a  measure  separate  and  distinct,  are  intended  to 
work  in  connection  with  each  other  and  to  afford  complete  protec- 
tion against  the  importation  of  contagious  and  infectious  disease 
through  the  medium  of  the  commerce  which  seeks  the  port  of  Phila- 
delphia and  the  ports  of  entry  on  Delaware  Bay,  and  situated  in  the 
States  of  Delaware,  New  Jersey,  and  Pennsylvania.  At  the  station 
at  Delaware  Breakwater,  which  is  situated  at  the  mouth  of  Delaware 
Bay  and  immediately  upon  the  point  formed  by  Cape  Henlopen,  is 
the  reservation,  forty  acres  in  extent,  and  surrounded  by  a  substantial 
picket-fence  ten  feet  in  height.  Within  this  enclosure  is  located  the 
quarantine  plant  proper,  consisting  of  commodious  hospitals  for  con- 
tagious and  non-contagious  diseases,  and  barracks  for  the  accommo- 
dation of  one  thousand  suspects,  fitted  with  bunks  and  provided  with 
bedding  and  a  full  supply  of  clothing  for  both  males  and  females. 
In  conneclion  with  these  barracks  are  a  large  kitchen,  fully  equipped 


528  TEXT-BOOK  OF  HYGIENE. 

with  steam  cooking-apparatus  of  the  most  improved  description  and 
a  commodious  mess-halL  There  has  been  also  provided  a  building 
containing  a  boiler  for  operating  the  pumps,  a  bath-house,  and  laun- 
dry, which  latter  is  equipped  with  appliances  for  washing  all  soiled 
clothing  and  for  subjecting  them  to  the  boiling  process.  In  this 
building  there  is  also  located  a  steam  disinfecting  chamber  of  the 
most  modern  and  improved  type,  and  adjoining  this  building  is  a 
bath-house  fitted  with  twenty  shower-  and  two  tub-baths,  all  pro- 
vided with  hot  and  cold  water.  An  artesian  well  has  been  sunk, 
capable  of  supplying  twenty  thousand  gallons  of  water  per  day,  and 
this  water  is  raised  by  a  powerful  pump  to  elevated  tanks,  and  from 
these  distributed  to  the  barracks,  kitchens,  hospitals,  laundry,  and 
bath-house. 

Latrines  are  provided  and  furnished  with  iron  containers  hold- 
ing a  strong  disinfecting  solution,  and  provision  is  made  for  empty- 
ing these  containers  into  a  sewer,  which,  in  turn,  empties  into  a  sewer 
common  to  the  bath-house  and  laundry,  which  discharges  into  the  sea. 
The  danger  of  soil  contamination  by  alvine  discharges  is  reduced  to 
a  minimum,  and  the  water-supply  likewise  protected.  Outside  of  the 
fence  is  a  large  brick  house,  which  furnishes  executive  and  admin- 
istrative offices  and  quarters  for  the  medical  officers  on  duty  at  the 
station.  In  front  of  the  executive  building  is  a  lofty  flag-staif,  which 
affords  the  means  for  communicating  by  signals  with  vessels  in  quar- 
antine and  arriving  in  the  offing. 

Within  a  few  hundred  yards  of  the  reservation  is  a  long  iron 
pier,  which  affords  ample  facilities  for  the  landing  of  passengers. 

Situated  fifty-five  miles  above  the  Breakwater,  and  forty-five 
miles  from  Philadelphia,  is  the  Eeedy  Island  Quarantine  Station,  on 
and  near  the  island  of  that  name.  Upon  the  island  itself  are  situ- 
ated the  residence  of  the  medical  officer,  quarters  for  employees,  and 
a  cottage  hospital.  A  boat-house  is  connected  with  the  island  by  a 
gangway.  The  quarantine  plant  proper  is  located  on  a  pier  situated 
on  the  edge  of  the  channel,  and  in  thirty  feet  of  water.  The  pier  is 
two  hundred  feet  in  length,  and  presents  a  frontage  of  nearly  four 
hundred  feet,  owing  to  the  placing  of  an  ice-break  above  and  below  the 
pier.  This  affords  room  for  the  accommodation  of  the  largest  vessels, 
and  upon  the  wharf  is  situated  the  disinfecting  plant,  consisting  of 
two  steam  chambers ;  a  sulphur-furnace,  fan  and  engine  for  driving 
the  same;  tanks  for  disinfecting  solutions  and  a  pump  and  hose  for 
their  distribution ;  a  fire-pump,  and  tanks  for  the  storage  of  water 
for  fire  and  steaming  purposes. 


THE  NATIONAL  QUARANTINE  SERVICE.-  529 

There  are  only  small  barracks  at  this  station,  it  being  the  plan 
that  the  vessel  shall  receive  quarantine  treatment  at  this  point,  and 
that  the  passengers  shall  undergo  their  detention  in  the  barracks  at 
the  Breakwater  station. 

Another  national  station  which  deserves  special  notice  from  its 
peculiarities  is  the  quarantine  vessel  Jamestown,  which  can  be  con- 
sidered a  floating  quarantine  station.  The  Jamestown  was  turned 
over  to  the  U.  S.  Marine-Hospital  Service  by  the  ISTavy  Department 
for  quarantine  use.  She  is  one  of  the  old-fashioned  sailing-vessels  of 
the  nav}^  is  very  strongly  and  solidly  constructed,  and  is  one  hundred 
and  sixty-six  feet  long,  thirty-six  feet  beam,  and  has  a  displacement 
of  eight  hundred  and  eighty-eight  tons.  She  has  been  fitted  for  her 
present  use  by  being  housed  in,  and  there- have  been  placed  on  board 
a  steam  disinfecting  chamber,  a  sulphur-furnace,  tank  for  bichloride 
solution,  and  bath-rooms.  In  addition  to  these,  she  has  been  fitted 
as  a  place  of  detention  for  tAvo  hundred  and  fifty  to  three  hundred 
immigrants,  and  is  in  all  respects  a  complete  quarantine  station,  and 
capable  of  doing  valuable  service  in  smooth  water. 

AIDS  TO  NATIONAL  QUARANTINE. 

In  aid  of  the  national  quarantines,  sanitary  inspectors  are  ap- 
pointed by  the  Marine-Hospital  Service  at  special  points  of  danger, 
either  in  the  United  States  or  abroad.  Through  the  State  Depart- 
ment consular  notification  from  foreign  ports  is  received  regularly  by 
mail,  or,  in  emergency,  by  cable,  and  the  information  thus  received, 
and  that  received  also  from  home  ports,  is  communicated,  by  the 
Marine-Hospital  Bureau,  to  all  quarantine  authorities,  and  others,  by 
means  of  a  weekly  publication  known  as  the  "Public  Health  Eeports." 

An  important  source  of  information  concerning  the  movements 
of  vessels  in  every  portion  of  the  world  is  the  "Maritime  Eegister," 
published  in  New  York.  The  United  States  Collectors  of  Customs 
are  efficient  aids,  having,  by  law,  the  power  of  search  and  detention 
of  vessels,  and  having  exceptional  knowledge  of  the  sanitary  condi- 
tion of  the  shipping  at  their  respective  ports.  The  Eevenue-Cutter 
Service,  a  national  coast  patrol,  gives  frequent  and  efiicient  aid;  the 
Light-house  Establishment  and  Coast  Survey  render  valuable  assist- 
ance in  locating  and  buoying  the  anchorages,  and  the  Life-Saving 
Service,  with  its  constant  patrol  of  the  coast,  guards  against  the  entry 
of  a  vessel  at  an  unusual  point.  The  surf-men  are  required  to  rake 
together  and  destroy  dunnage  and  other  material  likely  to  be  infected 
that  have  been  tlirown  overboard   and  washed  ashore  from  infected 

34 


530  •  '.TEXT-BOOK  OF  HYGIENE. 

vessels.  Finally,  the  Marine-Hospital  Service,  having,  besides  the 
quarantines,  the  care  of  the  sick  of  the  merchant  vessels  of  the  United 
States,  with  one  hundred  and  twenty-six  physicians  stationed  at  the 
larger  and  many  of  the  smaller  ports,  is  ready  at  a  moment's  notice 
to  extend  indefinitely  its  quarantine  service. 

NATIONAL  INSPECTION  OF  ALL  QUARANTINES. 

The  Act  of  Congress  approved  February  15,  1893,  while  con- 
templating that  State  and  local  quarantines  shall  not  be  disturbed 
in  the  exercise  of  their  functions,  provided  said  quarantines  are  ad- 
ministered in  accordance  with  the  law  and  the  regulations  made  there- 
under, further  provides  that  the  rules  and  regulations  of  local  quar- 
antines shall  be  examined  by  the  Surgeon-General  of  the  Marine- 
Hospital  Service,  and  also  that  such  additional  rules  and  regulations 
as  may  be  deemed  necessary  shall  be  made  by  the  Secretary  of  the 
Treasur}^,  and  shall  be  enforced  by  the  State  or  local  quarantine  au- 
thorities. If  the  latter  refuse,  or  are  unable  to  enforce  them,  the  law 
further  provides  that  the  President  of  the  United  States  shall  detail 
or  appoint  an  officer  for  this  purpose.  To  carry  out  the  intent  of  this 
law  all  the  quarantines  of  the  United  States,  national.  State,  and  local, 
are  inspected  periodically  by  an  officer  of  the  Marine-Hospital  Service. 
Following  are  the  instructions  prepared  for  the  inspecting  officers : — 

Instructions  to  Medical  Officers  of  the  Marine-Hospital 

Service  Detailed  to  ]\Iake  Inspections  of 

State  and  Local  Quarantines. 

Treasury  Regulations. 

*  *  *  *  *  *  *  *  * 

In  the  performance  of  the  duties  imposed  upon  him  by  the  act 
of  February  15,  1893,  the  Supervising  Surgeon-General  of  the  Marine- 
Hospital  Service  shall,  from  time  to  time,  personally  or  through  a 
duly-detailed  officer  of  the  ]\Iarine-Hospital  Service,  inspect  the  mari- 
time quarantines  of  the  United  States,  State  and  local,  as  well  as 
national,  for  the  purpose  of  ascertaining  whether  the  quarantine  regu- 
lations prescribed  by  the  Secretary  of  the  Treasury  have  been,  or  are 
being,  complied  with.  The  Supervising  Surgeon-General,  or  the 
officer  detailed  by  him  as  inspector,  shall,  at  his  discretion,  visit  any 
incoming  vessel,  or  any  vessel  detained  in  quarantine,  and  all  por- 
tions of  the  quarantine  establishment  for  the  above-named  purpose, 


NATIONAL  INSPECTION  OF  ALL  QUARANTINES.  531 

and  with  a  view  to  certifying,  if  need  be,  that  the  regulations  have 
been,  or  are  being,  enforced. — J.  Gr.  Carlisle,  Secretary. 

General  Instructions. 

A.  Your  inspections  will  include  all  ports  within  your  district 
where  vessels  are  allowed  to  enter  and  discharge  cargo,  and  ports 
which  may  be  used  as  ports  of  call. 

B.  A  separate  report  will  be  made  of  each  station  visited. 

C.  Visit  every  part  of  the  quarantine  establishment,  and  take 
necessary  precautions  to  prevent  the  conveyance  of  contagious  or  in- 
fectious disease  through  the  medium  of  your  own  person. 

D.  Visit  the  custom-house  for  the  purpose  of  ascertaining  whether 
the  regulations  with  regard  to  bills  of  health  and  quarantine  certifi- 
cates are  being  observed;  also,  the  immigration  station  for  any  perti- 
nent information. 

E.  Reports  of  a  statistical  character  and  descriptive  of  the  quar- 
antine, called  for  herein,  need  be  made  but  once  in  every  six  months, 
namely,  on  the  date  nearest  the  1st  of  January  and  the  date  nearest 
the  1st  of  July;  but  any  changes  that  have  been  made  since  the  last 
general  report  should  be  immediately  recorded. 

In  making  your  report  you  will  follow  the  special  instructions  in 
their  order,  referring  to  each  by  number. 

Special  Instructions. 

1.  Describe  the  quarantine  station,  location,  buildings,  anchor- 
ages, etc.  Give  limits  of  anchorage  for  non-infected  and  for  infected 
vessels;  facilities  for  inspection  of  vessels;  apparatus  for  disinfec- 
tion of  vessels  and  of  baggage;  facilities  for  removal  and  treatment 
of  the  sick,  and  for  the  removal  and  detention  of  suspects ;  mail  and 
telegraph  facilities,  etc. 

2.  Give  personnel  of  the  station  or  port;  name  of  the  quarantine 
officer  or  officers;  post-office  address;  total  number  of  officers  and 
subordinates,  etc. 

3.  Transmit  copies  of  the  laws  under  which  the  local  quarantine 
is  maintained,  and  copies  of  the  quarantine  regulations;  also  describe 
the  quarantine  customs  of  the  port  as  they  are  carried  out. 

Note. — There  are  sometimes  slif^ht,  but  possibly  important,  variations 
from  the  letter  of  the  local  refrnlations  in  the  administration  of  quarantine. 
Also,  local  rcfjulations  (generally  allow  a  wifle  latitude  to  the  quarantine 
officer,  and  how  this  latitude  is  used — i.e.,  how  the  quarantine  oflfieer  inter- 
prets the  spirit  of  the  rcj^ulations — is  very  important. 


532  TEXT-BOOK  OF  HYGIENE. 

4.  State  what  quarantine  procedures,  either  under  printed  regu- 
lations or  by  customy  are  enforced  at  the  port,  in  addition  to  the 
requirements  of  the  Treasury  Department. 

It  should  also  be  stated  whether  there  is  undue  or  unnecessary 
detention  or  disinfection  of  vessels. 

5.  State  whether  the  inspection  is  maintained  throughout  the 
year  or  for  what  jjeriod,  and  what  treatment  of  vessels  is  enforced 
during  the  entire  year. 

6.  Are  vessels  from  other  United  States  ports  inspected? 

7.  Describe  quarantine  procedures  in  the  inspection  of  vessels, 
and,  if  infected,  the  treatment.  Give  time  in  quarantine  (a)  between 
arrival  and  commencement  of  disinfection,  {b)  time  occupied  by  dis- 
infection, and  (c)  time  after  completion  of  disinfection  of  vessels  until 
discharge. 

Note. — Quick  or  slow  handling  of  a  vessel  is  of  more  importance  com- 
mercially than  the  question  of  fees.  The  time  lost  is  the  vessel's  heaviest 
expense,  generally. 

8.  What  communication  is  held  with  vessels  in  quarantine  (and, 
before  quarantine,  by  pilots,  etc.),  and  how  regulated?  Is  there  any 
intercommunication  allowed  among  vessels  in  quarantine? 

9.  State  what  will  be  done  with  a  vessel  infected  with  cholera; 
second,  a  vessel  infected  with  yellow  fever;  third,  a  vessel  infected 
with  small-pox  (said  vessels  carrying  or  not  carrying  immigrants), 
and  what  conditions  are  regarded  as  giving  evidence  of  the  vessel's 
infection  in  each  case. 

10.  State  whether  records  are  kept,  at  the  station,  of  the  cases 
of  disease  that  have  occurred  during  the  voyage,  on  arrival  and  during 
detention, 

11.  Transmit  schedule  of  quarantine  fees,  and  give  other  fees  and 
expenses  necessarily  and  usually  attendant  on  quarantine,  as  tonnage, 
ballast,  wharfage  charges,  etc. 

12.  Make  a  statement  showing  the  number  of  vessels  arriving  at 
the  port  during  the  preceding  calendar  year,  by  months,  (a)  from 
foreign  ports;  (&)  from  foreign  ports  in  yellow-fever  latitudes  via 
domestic  ports;  (c)  from  domestic  ports.  Show,  also,  the  character 
of  the  commerce  carried  on  by  the  port — i.e.,  from  what  countries 
chiefly  the  vessels  come,  and  whether  in  cargo,  ballast,  or  empty. 

13.  State  results  of  your  visit  to  {a)  the  Custom-house;  (&)  the 
Immigration  Bureau. 

14.  State  whether,  in  3'our  opinion,  the  quarantine  facilities  are 
sufficient  to  care  for  the  shipping  entering  the  port. 


INLAND  QUARANTINE.  533 

15.  JSTame  the  quarantine  regulations  of  the  Treasury  Depart- 
ment which  are  not  properly  enforced,  and  state  specifically  whether 
the  regulations  regarding  inspection  and  disinfection,  and  particularly 
the  period  of  observation  after  disinfection,  of  vessels  are  observed. 

16.  Mention  any  facts  which,  in  your  opinion,  should  be  known 

to  the  Department,  bearing  directly  or  indirectly  upon  the  quarantine 

service,  and  make  such  recommendations  as  seem  proper. — Walter 

Wtman,  Surgeon-General. 

Note. — Report  to  be  written  on  legal-cap  paper  (on  one  side  only), 
signed,  and  inclosed  in  this  blank  as  a  cover. 

INLAND  QUARANTINE. 

Under  Inland  Quarantine  will  be  described  The  Sanitary  Cordon, 
Camps  of  Probation,  Eailroad  Quarantine,  Disinfection  Stations,  and 
Inspection  Service. 

THE  SANITARY  CORDON. 

This  consists  of  a  line  of  guards,  military  or  civil,  thrown  around 
a  district  or  localit}^,  either  to  protect  the  same  from  the  surrounding 
country  when  infected,  or  to  protect  the  surrounding  country  from 
the  infected  district  or  locality.  When  a  given  locality  is  infected,  and 
the  adjacent  territory  is  regarded  as  suspicious,  it  may  be  necessary  to 
establish  a  double  cordon,  the  first  one  embracing  the  whole  suspected 
territory  at  its  outer  edge,  the  second  investing  more  closely  the  well- 
defined  infected  locality.  After  the  expiration  of  a  sufiicient  time  to 
prove  that  the  area  between  the  cordons  is  not  infected,  or  has  been 
cleared  of  infection,  the  first  cordon  may  be  removed.  Hospitals  and 
camps  of  probation  may  be  necessary  adjuncts  to  the  cordon.  The 
most  noted  example  of  the  sanitary  cordon  is  found  in  the  history 
of  the  plague-epidemic  in  Eussia  in  1878.  A  colony  on  the  river 
Volga,  called  Wetljankaja,  with  a  population  of  1700  inhabitants, 
Ijecame  infected  with  the  Oriental  plague,  which  extended  to  the 
neighboring  villages.  A  military  cordon  was  made  to  embrace  all 
the  infected  district.  The  inhabitants  of  the  focus  of  infection, 
Wetljankaja,  were  removed,  property  appraised  for  re-imbursement 
by  the  government,  and  the  village  burned.  An  additional  cordon 
was  thrown  around  Zarizin,  a  neighboring  commercial  city  of  impor- 
tance and  terminus  of  the  I'ussian  railway  system.  The  cordons  were 
maintained  several  months,  and  the  plague  was  stamped  out.  (See 
Abstract  Sanitary  I'eports,  vol.  i   [Bulletin's],  page  78.)     The  sani- 


534  TEXT-BOOK  OF  HYGIENE. 

tary  cordon  is  the  customary  method  of  preventing  the  spread  of 
epidemic  disease  in  the  eastern  countries. 

In  the  United  States,  when  yellow  fever  prevailed  in  Pensacola, 
in  1882,  to  the  extent  of  3300  cases,  the  navy-yard  reservation,  whose 
boundary-line  is  within  two  miles  of  the  city  limit,  and  with  a  popu- 
lation of  about  1500,  was  successfully  guarded  by  means  of  a  cordon 
and  non-intercourse. 

The  following  year,  1883,  the  navy-yard  itself  was  infected,  and 
a  cordon  was  thro'WTi  around  it  to  protect  the  city  of  Pensacola,  and 
was  maintained  for  a  period  of  sixty  days.  This  cordon  was  under 
the  management  of  the  Surgeon-General  of  the  Marine-Hospital 
Service,  aid  having  been  requested  of  the  national  government.  The 
Collector  of  Customs  of  Pensacola  was  made  the  agent  to  execute  the 
orders  of  the  Marine-Hospital  Bureau,  and  to  the  President  of  the 
local  Board  of  Health  was  intrusted  the  immediate  command  of  the 
line  and  guards.  The  cordon  entirely  surrounded  the  land-boundary 
of  the  naval  reservation.  Its  line  was  four  miles  in  length,  one 
mile  of  it  through  a  dense  thicket,  and  was  marked  by  blazed  trees  and 
flags.  Forty  men  were  employed  as  guards,  an  equal  number  being 
selected  from  each  of  the  two  political  parties.  Two  captains  were 
appointed,  and  were  obliged  to  supervise  the  line  night  and  day. 

The  sentinel  posts  were  furnished  with  tents,  and  two  guards 
were  allotted  to  each  post,  taking  alternate  watches  of  four  hours 
each.  A  detention  or  probation  camp  was  established  and  placed  in 
charge  of  a  physician,  where  persons  wishing  to  leave  the  reservation 
were  obliged  to  pass  a  probationary  period  of  twenty  days.  Not  more 
than  half  a  dozen  persons  were  received  in  this  camp.  The  govern- 
ment expended  about  $20,000  in  these  restrictive  measures,  which 
were  entirely  successful.  Not  one  person  got  through  the  cordon  line. 
The  success  was  due  largely  to  the  thorough  discipline  maintained 
by  the  Collector  and  the  President  of  the  Board  of  Health. 

Yellow-fever  Cordon  in  Texas. — In  1882,  yellow  fever  prevail- 
ing in  Mexico,  along  the  Eio  Grande,  and  in  Brownsville,  Texas,  a 
sanitary  cordon  was  established  by  the  Surgeon-General  of  the  Marine- 
Hospital  Service,  on  request  of  the  Governor  of  the  State,  extending 
along  the  line  of  the  railroad  from  Corpus  Christi,  on  the  Gulf  of 
Mexico,  inland  to  Laredo,  on  the  Eio  Grande.  This  line  was  one 
hundred  and  eighty  miles  northeast  of  Brownsville,  the  triangular 
territory  thus  hemmed  in  by  the  cordon  on  one  side,  the  Eio  Grande 
on  another,  and  the  Gulf  on  the  third,  being  all  suspected  territory, 
although  the  fever  prevailed  in  only  one  corner  of  it — viz. :  in  Browns- 


INLAND  QUARANTINE.  535 

ville.  All  persons  were  detained  at  least  ten  days  at  the  cordon  before 
being  allowed  to  pass  northward — a  period  of  probation  to  insure  that 
no  one  having  the  disease  should  carry  it  farther  north.  As  soon  as 
practicable  another  cordon  was  established  much  nearer  to  Browns- 
ville, only  thirty  miles  from  it,  the  line  extending  from  the  mouth 
of  the  Sol  Colorado,  on  the  Gulf  of  Mexico,  to  Santa  Maria,  on  the 
Eio  Grande.  After  a  time  sufficient  to  prove  that  no  more  fever 
prevailed  between  the  two  cordons,  the  first  one  was  removed.  Within 
the  second  line,  where  the  fever  prevailed,  chiefly  in  Brownsville,  a 
hospital  was  established  and  dispensaries  opened  for  the  gratuitous 
treatment  of  all  applicants. 

Upon  the  Mexican  side  of  the  Eio  Grande  the  fever  continued 
to  spread  northwardl}^,  and,  in  order  to  oppose  it,  still  another  cordon 
had  to  be  established  on  the  American  side  of  the  river,  extending 
from  Santa  Maria  on  the  south  to  Laredo  on  the  north,  a  distance  of 
five  hundred  miles.  Three  hundred  guards,  well  mounted  (Texan 
cow-boys),  were  employed  in  this  cordon,  and,  while  the  disease  was 
being  stamped  out  in  Brownsville,  any  further  importation  from 
Mexico  was  thus  prevented.  In  Mexico  the  fever  continued  to  spread 
until  the  authorities  finally  adopted  measures  similar  to  the  above. 

The  epidemic  of  yellow  fever  in  Brunswick,  Ga.,  in  1893,  gave 
rise  to  the  necessity  of  establishing  a  sanitary  cordon  to  protect  the 
surrounding  country  from  the  danger  incident  to  the  ]3anic-engen- 
dered  flight  of  the  inhabitants  of  that  town.  On  account  of  the 
peculiar  situation  of  Brunswick  the  difficulties  to  be  met  were  very 
great.  Not  only  were  numerous  roads  to  be  guarded,  but  three  water- 
passages  from  the  city  into  the  surrounding  country  had  also  to  be 
watched.  The  cordon,  therefore,  partook  of  the  nature  of  both  a  land 
and  water  patrol,  and  the  difficulties  were  successfully  overcome,  and 
no  well-authenticated  instances  of  escape  through  the  lines  were  estab- 
lished. 

Much  violent  language  has  been  used  concerning  the  hardships 
imposed  by  the  sanitary  cordon,  but  in  the  presence  of  an  epidemic 
the  authorities  who  are  responsible  need  to  pay  more  heed  to  the 
efficiency  of  the  cordon  than  to  individual  complaints.  It  should  be 
borne  in  mind  that  the  sanitary  cordon  is  not  intended  to  bottle  up 
all  the  people  who  are  caught  within  an  infected  district.  On  the 
contrary,  it  is  intended  as  a  means  of  exit  to  those  who  will  not  carry 
with  them  contagious  disease  to  the  people  bej'oud. 

The  cordon,  then,  imposes  simply  a  period  of  detention  corre- 
sponding to  the  incubative  pei'iod  of  the  prevailing  disease.     Ample 


536  TEXT-BOOK  OF  HYGIENE. 

preparation  must  be  made  for  housing  and  feeding,  in  camps  or  other 
quarters,  persons  awaiting  the  expiration  of  the  detention  period ;  and 
hospitals  must  be  provided  for  the  treatment  of  those  who  develop 
sickness.  Provision  must  also  be  made  for  the  disinfection  of  sus- 
pected baggage. 

CAMPS  OF  PROBATION. 

Camps  of  probation  or  detention  should  be  established  with  all 
the  precision  of  arrangement  and  regard  for  site,  water,  and  drainage 
that  pertain  to  a  military  camp.  Every  effort  should  be  made  to  make 
the  camp  as  comfortable  and  cheerful  as  possible,  and  to  this  latter 
end  amusements  and  entertainments  such  as  might  be  suggested  by 
the  campers  themselves  should  be  encouraged.  Every  necessity  in 
the  matter  of  food,  bedding,  and  the  ordinary  comforts  of  life  should 
be  anticipated,  to  prevent  any  just  cause  of  complaint.  Such  a  nat- 
ural division  of  the  inhabitants  should  be  made  as  seems  desirable  at 
the  time,  those  of  equal  intelligence  and  refinement  naturally  seeking 
each  other's  company.  The  greatest  concern  is  to  prevent  the  camp 
itself  from  becoming  infected.  To  this  end  no  baggage  should  be 
allowed  within  the  camp-boundary  without  previous  examination  or 
fumigation,  to  ensure  its  freedom  from  mosquitoes ;  and  every  refugee 
should  be  examined  by  a  physician  before  being  admitted  to  the  camp. 
jSTo  one  should  be  received  who  does  not  intend  to  proceed  to  an  im- 
infected  locality  after  his  probation.  In  other  words,  a  camp  of 
probation  should  not  be  used  as  one  of  refuge. 

The  camp  must  be  surrounded  by  guards  to  prevent  egress  or 
ingress,  excepting  through  the  established  portal.  At  least  twice  or 
three  times  in  the  twenty-four  hours  all  refugees  should  be  inspected 
in  their  quarters,  and  any  case  of  sickness  at  once  be  isolated  and 
watched  and  screened  from  mosquitoes  until  the  diagnosis  is  certain. 
If  the  case  is  one  of  the  prevailing  disease,  the  patient  must  be  re- 
moved immediately  to  the  hospital,  which  should  be  at  a  safe  distance, 
half  a  mile  or  more,  from  the  camp.  Before  leaving  the  camp,  cloth- 
ing should  be  fumigated  to  destroy  mosquitoes,  and  he  should  be  given 
a  certificate  that  he  has  passed  the  required  period  of  probation.  A 
clear  distinction  must  be  made  between  camps  of  probation  and  camps 
of  refuge.  Camps  of  refuge  are  simply  residence  camps  established  to 
receive  the  population  of  an  infected  community,  Avhen  it  has  been 
determined  to  depopulate  the  infected  district. 

Depopulation  of  a  house,  a  block,  a  district,  or  a  whole  city,  if 
possible,  the  people  moving  into  camps,  is  now  reco,o;nized  as  a  valu- 


INLAND  QUARANTINE.  537 

able  means  of  controlling  an  epidemic ;  and  there  may  be  either  camps 
of  probation  or  simply  camps  of  refuge,  or  both,  according  to  the 
requirements  of  the  situation.  Camps  of  refuge,  in  connection  with 
depopulation,  were  suggested  by  the  late  Surgeon-General  Woodworth, 
in  1878,  and  the  measure  was  practically  carried  out  at  Memphis,  in 
1879,  by  the  establishment  of  Camp  Mitchell.  "But  the  establish- 
ment of  a  camp  to  which  persons  from  infected  points  could  go,  be 
kept  under  observation  a  sufficient  length  of  time  to  demonstrate  they 
were  not  infected,  have  their  baggage  disinfected,  and  be  given  'free 
pratique,'  is  apparently  a  new  departure  in  inland  quarantine." 

Camp  Perry,  Fla. — Such  was  Camp  Perry,  Florida,  described  by 
the  surgeon  in  charge,  W.  H.  H.  Hutton,  in  the  Marine-Hospital 
Service  Report  for  1889.  The  site  was  admirably  chosen  by  Passed 
Assistant  Surgeon  John  Guiteras,  upon  a  bluff  on  the  south  side  of 
St.  Mary's  Eiver,  the  dividing  line  between  Florida  and  Georgia,  about 
forty  miles  north  of  Jacksonville,  Fla.,  which  city  was  in  the  throes 
of  a  yellow-fever  epidemic.  The  camp  was  opened  August  20,  1888. 
It  consisted,  in  its  completed  stage,  first,  of  50  wooden  cottages  built 
elsewhere  and  transported  on  cars.  Their  dimensions  were  12  feet 
by  10,  and  10  feet  in  height,  constructed  of  plain  lumber,  with  cracks 
battened,  and  windows  on  each  side  with  swinging  shutters.  Each 
held  four  cots,  chairs,  and  toilet-stand,  while  unused  clothing  was 
neatly  arranged  on  the  rafters  above.  Besides  the  50  cottages  there 
were  a  quartermaster  and  guard-house,  commissary  building,  dining- 
room  and  kitchen,  and  laundry,  built  of  rough  lumber;  2  Ducker 
portable  barracks,  each  18  by  35  feet,  provided  with  12  beds  each,  and 
350  tents,  used  principally  by  the  single  men,  the  employees  and 
guards,  and  the  colored  refugees.  So  far  as  known,  this  is  the  first 
camp  of  the  kind  ever  established ;  at  least,  in  the  United  States.  The 
cottages  were  arranged  in  a  quadrangle  around  a  parade-ground  two 
acres  in  extent,  and  the  tents  were  arranged  in  streets  and  alle3'^s  in 
the  rear  of  the  cottages.  The  accommodations  were  sufficient  for 
600  people,  and  extra  tents  were  on  hand  so  that,  if  required,  1000 
persons  could  have  been  provided  for,  or  3000  per  month,  allowing 
for  only  ten  clays'  detention  of  each  person.  Two  himdred  hospital 
tents  will  accommodate  1200  people  comfortably,  according  to  Sur- 
geon Hutton,  wbo  states  that  the  small  A-tents  are  unsuited  for 
women  and  children,  but  will  answer  for  men  or  boys.  Wire-mattress 
cots  should  be  provided.  The  Marine-Hospital  officer  at  Savannah, 
Ga.,  was  the  purchasing  agent  for  the  camp,  and  promptly  forwarded 
all  subsistence  supplies  on  requisition  by  mail  or  telegraph. 


538  TEXT-BOOK  OF  HYGIENE. 

Discipline  of  the  Camp. — On  arrival  of  a  train,  each  passenger 
was  personall}^  examined  by  a  physician,  his  health-certificate  scruti- 
nized, and  he  was  made  to  await  the  examination  of  others.  Hand- 
bags, clothing,  and  loose  wearing-apparel  were  left  in  the  baggage-car 
for  disinfection.  The  refugees  were  then  conducted  to  the  quarter- 
master's room  for  registration  and  assignment  to  quarters.  On  first 
arrival  they  were  placed  in  the  southern  part  of  the  camp,  and  in  two 
days,  there  being  no  sickness,  Avere  moved  forward  several  cabins,  and 
this  progression  was  repeated  until  the  time  for  discharge. 

Twelve  guards  were  employed,  under  the  command  of  a  captain, 
and  were  divided  into  squads  of  four  each.  The  schedule  was  so 
arranged  that  each  guard  was  on  duty  two  hours  and  off  duty  four. 

A  bugler  announced  the  several  calls,  as  follow: — 

5.30  A.M Reveille. 

6.00  A.M Breakfast,  employes. 

7.00  A.M Breakfast,  guests. 

9.00  A.M Surgeon's  call  and  inspection. 

12.00      M Dinner,  employes. 

1.20  P.M Dinner,  guests. 

4.30  P.M Surgeon's   call   and   inspection, 

5.30  P.M Supper,  guests. 

6.00  P.M Supper,  employes. 

6.30  P.Jr Retreat  and  change  of  guard. 

9.00  P.M Retiring  taps. 

The  yellow -fever  hospital  camp,  under  the  special  charge  of  Dr. 
Faget,  was  located  one-half  mile  from  the  probation  camp.  It  con- 
sisted of  2  frame  buildings,  2  hospital  and  12  smaller  tents,  arranged 
in  a  double-crescent  shape,  the  avenue  in  the  middle  presenting  an 
attractive  appearance. 

Of  the  12  small  tents,  4  were  for  nurses,  3  for  emploj^ees,  2  for 
convalescents,  and  1  each  for  drug-store,  storage-  and  dead-house. 
One  of  the  hospital  tents  was  used  as  a  dining-room  for  employees, 
convalescents,  and  parents  of  the  sick. 

The  hospital  was  established'  September  3,  1888,  and  between 
that  date  and  November  24th  35  cases  of  yellow  fever  were  admitted 
and  treated,  3  died,  and  32  were  discharged.  Twelve  hundred  and 
eleven  refugees  were  received  into  Camp  Perry,  nearly  all  of  whom 
were  from  the  infected  district  of  Jacksonville. 

Thirty-five  cases  of  yellow  fever  were  caught  by  the  ten  days' 
detention,  but  no  case  of  fever  was  contracted  at  the  camp,  and  of 
the  1208  refugees  who  passed  the  required  detention  and  proceeded 
to  different  parts  of  the  country,  so  far  as  known,  not  one  subsequently 


INLAND  QUARANTINE.  539 

developed  or  carried  the  disease  elsewhere.  The  general  plan  of  the 
preventive  measures  adopted  during  this  epidemic  will  be  described 
under  Eailroad  Quarantine. 

Detention  Camp,  Waynesville,  Ga. — The  epidemic  of  yellow  fever 
in  Brunswick,  Ga.,  in  1893,  caused  the  establishment  of  another  camp 
of  probation  near  Waynesville,  Ga.  Following  is  the  report  of  the 
medical  officer  in  command : — 

"Sir:  I  have  the  honor  to  present  the  following  report  of  the 
operations  of  the  detention  camp  near  Waynesville,  Ga. 

"The  camp  was  officially  opened  for  the  reception  of  refugees 
from  Brunswick,  Ga.,  on  the  18th  of  September,  1893,  and  closed  by 
the  order  of  Surgeon,  E.  D.  Murray,  Marine-Hospital  Service,  per- 
mitting the  return  of  all  refugees  to  their  homes  in  Brunswick,  No- 
vember 30,  1893. 

"Four  hundred  and  thirty-one  persons  availed  themselves  of  the 
privileges  of  the  camp,  of  whom  about  two  hundred  and  twenty-five 
were  white  and  the  remainder  black  and  colored. 

"The  site  of  the  camp  was  selected  by  Surgeon  W.  H.  H.  Hutton, 
and  was  twenty-three  miles  west  of  Brunswick,  immediately  upon  and 
on  the  south  side  of  the  Brunswick  and  Western  Eailway,  and  upon 
an  eminence  about  twenty-five  feet  above  the  level  of  the  surrounding 
countrjr,  which  is  generally  swampy,  and  within  a  mile  of  the  margin 
of  what  is  locally  known  as  the  Buffalo  Swamp.  As  is  usual  in  this 
section,  the  elevation  was  covered  with  a  dense  growth  of  yellow-pine, 
scrub-oak,  and  black-gum  trees.  The  soil  was  a  gray,  sandy  loam, 
overlying  a  stratum  of  yellow  clay,  and  the  natural  drainage  of  the 
site  in  all  directions  was  good. 

"On  my  arrival  I  found  that,  under  the  direction  of  Surgeon 
Hutton,  an  area  of  two  hundred  feet  had  been  cleared  of  trees  and 
undergrowth,  and  at  the  four  corners  of  this  square  rough  but  sub- 
stantial buildings  had  been  erected,  which  were  used,  respectively,  as 
kitchen,  white  and  colored  dining-rooms,  guard-room,  quartermaster's 
store-room,  executive  office,  telegraph  office,  and  commissary.  A  depot 
and  baggage-room  were  provided  at  the  railway.  Along  the  lines  con- 
necting these  buildings,  at  intervals  of  twelve  feet,  were  placed  wall- 
tents,  twelve  by  fourteen  feet,  with  flies,  and  subsequently  further 
rows  of  tents  were  pitched  behind  these  and  opening  on  streets  four- 
teen feet  wiflo.  All  tents  were  provided  with  substantial  floors  raised 
six  inches  above  the  ground,  and  the  following  equipment  was  pro- 
vided: For  each  inmate,  one  spring,  wire-bottomed  cot,  one  cotton 
mattress,  one  hair  pillow,  two  sheets,  one  pillow-case,  and,  for  each 


540  TEXT-BOOK  OF  HYGIENE. 

tent,  two  tin  wash-bowls,  two  tin  cups,  and  two  wooden  chairs.  Ee- 
markable  ingenuity  was  displaj^ed  by  the  inmates  in  the  construction 
of  articles  of  furniture  from  packing-cases,  waste  lumber,  etc.  The 
tents  proved  of  good  quality  in  service,  and  quite  comfortable  in  all 
weather.  It  is  suggested,  however,  that  any  future  tents  be  constructed 
with  a  wall  two  feet  higher  and  of  one  foot  greater  pitch.  A  hospital 
establishment  of  two  buildings  was  provided  at  a  distance  of  one-half 
mile  from  the  camp.  A  lofty  pine-tree  was  fitted  with  a  topmast,  and 
served  as  a  staff  for  the  display  of  the  national  colors  from  sunrise 
to  sunset  each  day. 

"The  following  routine  was  observed,  the  calls  being  given  by  the 
bugle : — 

5.30  A.M Reveille  and  attendants'  breakfast. 

6.00  A.M Breakfast. 

8.00  A.M Sick  call. 

12.00      M Dinner. 

4.00  P.M Sick  call. 

5.00  P.M Supper. 

Sunset Retreat  and  call  to  quarters. 

9.00  P.M Tattoo. 

9.15  P.M Taps   (extinguish  lights). 

"The  meals  were  substantial,  abundant,  and  as  varied  as  possible. 
In  all  cases  women  and  children  were  served  at  the  first  table,  and  the 
races  were  served  in  separate  diningrroomsr 

"The  following  rules  were  announced,  and  seemed  to  work  well 
in  practice : — 

"1.  At  reveille  all  inmates  will  rise  and  prepare  for  breakfast. 

"2.  All  quarters  must  be  clean,  floors  swept,  and  beds  made  up 
before  first  sick  call. 

"3.  Meals  will  be  served  in  the  dining-rooms  only,  and  at  stated 
hours,  and  no  meals  shall  be  carried  from  the  dining-rooms  to  any 
quarters,  except  upon  the  written  order  of  the  medical  officer,  renewed 
from  day  to  day, 

"4.  At  sick  calls  all  inmates  will  repair  to  their  quarters,  and  be 
there  visited  and  inspected  by  the  medical  officer,  who  will  prescribe 
or  advise  as  he  may  deem  best. 

"5.  All  suspicious  cases  of  disease  will  be  isolated  at  once,  and 
until  such  time  as  the  nature  of  the  same  may  be  determined. 

"6.  All  cases  of  infectious  disease  will  be  treated  only  in  the  hos- 
pital provided  for  the  purpose. 

"7.  1^0  baggage  from  infected  localities  shall  be  brought  into 
camp  until  disinfected  by  such  process  as  may  be  directed,  and  only 


INLAND  QUARANTINE.  541 

such  wearing-apparel  as  may  be  deemed  absolutely  necessary  will  be 
brought  into  camp  after  the  disinfecting  process. 

"8.  All  wearing-apparel  shall  be  a  second  time  disinfected  before 
discharge  from  camp. 

"9.  Any  person  taken  ill  between  two  sick  calls  shall  at  once 
notify  the  nearest  guard,  who  will,  in  turn,  at  once  notify  the  medical 
officer. 

"10.  Guards  are  enjoined  by  their  vigilance  to  prevent  the  com- 
mission of  any  nuisance  near  any  quarters;  should  such  nuisance  be 
discovered,  the  inmates  of  the  nearest  quarters  will  be  required  to 
police  the  same  under  the  supervision  of  the  guard,  who  will  make 
report  of  the  same. 

"11.  Inmates  will  confine  themselves  to  the  inner  lines  of  the 
camp  after  retreat  (sunset)  call. 

"12.  While  innocent  enjoyment  will  be  encouraged,  the  strictest 
propriety  of  conduct  will  be  demanded  and  enforced. 

"The  discipline  of  the  camp  was,  in  the  main,  good  throughout. 
But  two  confinements  for  misbehavior  were  required  during  the  entire 
duration  of  the  camp. 

"All  baggage  was  submitted  to  steam  disinfection  upon  arrival 
at  and  departure  from  camp.  The  apparatus  used  was  devised  by 
Surgeon  H.  R.  Carter,  Marine-Hospital  Service,  and  was  constructed 
in  a  baggage-car,  the  steam  being  supplied  by  a  locomotive. 

"In  addition  to  other  duties,  nearly  sixteen  hundred  cars,  boxes, 
and  fiats  were  disinfected  for  the  B.  and  W.  Railway,  sulphur  fumi- 
gation being  used  for  the  boxes  and  drenching  with  acid  solution  of 
bichloride  of  mercury  (1  to  800)  for  flat  cars.  This  disinfection  of 
cars  enabled  the  traffic  into  Brunswick  to  be  carried  on  with  a  mini- 
mum of  delay  and  hardship. 

"Two  cases  of  yellow  fever  occurred  among  the  inmates  of  the 
camp,  one  resulting  in  recovery,  one  in  death.  Both  cases  occurred 
in  the  persons  of  sailors  who  had  arrived  in  Brunswick  on  vessels 
trading  there,  and  both  would  seem  to  show  a  period  of  incubation 
of  at  least  five  days,  thus  justifying  our  detention  of  ten  days." 

THE  INFLUENCE  OF  THE  MOSQUITO  UPON  THE  MANAGEMENT 
OF  YELLOW  FEVER. 

Such  was  formerly  the  routine  of  the  management  of  detention 
and  probation  camps.  With  the  aflvance  of  definite  knowledge  on 
tli(;  siibjfct  of  the  etiology  and  metbods  of  conveying  yellow  fever, 


542  TEXT-BOOK  OF  HYGIENE. 

this  would  be  modified  in  certain  particulars  where  the  camp  is  in- 
tended for  the  prevention  of  the  sj^read  of  yellow  fever.  The  disin- 
fection of  baggage  from  the  place  infected  with  yellow  fever  would 
no  longer  be  required  further  than  to  insure  the  destruction  of  mos- 
quitoes that  might  be  contained  therein;  and  the  methods  for  the 
prevention  of  yellow  fever  within  the  camp  from  eases  arising  in 
inmates  after  entry  would  be  limited  to  screening  them  from  the 
access  of  mosquitoes  and  to  the  elimination  of  places  and  conditions 
favorable  to  the  multiplication  of  the  Stegomyia  fasciata. 

THE    MANAGEMENT    OF    EPIDEMICS    OF    YELLOW    FEVER    IN 

THE   LIGHT   OF   THE    MOSQUITO   TRANSMISSION 

OF  THE  DISEASE. 

As  may  be  well  imagined,  the  promulgation  of  the  mosquito  doc- 
trine of  the  transmission  of  yellow  fever,  and  its  general  acceptance 
by  scientists  and  sanitarians,  has  necessitated  some  radical  departures 
in  the  handling  of  epidemics  of  yellow  fever.  Whereas  it  was  for- 
merly considered .  that  fomites  were  the  principal  agent  in  the  dis- 
semination of  the  infection,  it  is  now  generally  recognized  that  these 
articles  play  absolutely  no  role  in  the  transmission  of  the  disease,  and 
that  measures  for  the  suppression  of  an  epidemic  must  be  based  upon 
the  destruction  of  the  mosquito  of  the  genus  Stegomyia  fasciata  and 
the  shielding  of  actual  cases  of  yellow  fever  from  the  attacks  of  these 
insects.  It  seems  to  be  accepted  that  if  there  are  no  mosquitoes  of 
this  genus,  or  if  such  mosquitoes  are  not  allowed  to  bite  individuals 
sick  with  yellow  fever,  there  will  be  no  spreading  of  the  disease. 

The  following  extracts  from  publications  of  the  Public  Health 
and  Marine-Hospital  Service  show  clearly  the  basis  upon  which 
restrictive  epidemic  measures  are  founded,  and  the  report  of  the 
management  of  the  epidemic  of  yellow  fever  in  Laredo,  Texas,  and 
at  various  points  along  the  Texas-Mexican  border  in  1903,  give  a 
clear  idea  of  the  practical  application  of  measures  founded  upon  this 
doctrine. 

Par  from  making  the  work  of  the  sanitarian  more  easy,  this  doc- 
trine has  necessitated  more  rigorous  care  even  than  was  formerly 
necessary,  and  it  is  easy  to  see  that  a  failure  to  recognize  cases  early, 
to  screen  them  from  the  bites  of  mosquitoes,  or  to  destroy  mosquitoes 
and  the  places  favorable  for  their  breeding,  will  be  followed  by  disas- 
trous results  in  the  shape  of  a  spread  of  the  epidemic.  Cases  of  yellow 
fever  plus  the  existence  of  mosquitoes  of  the  genus  Stegomyia  fasciata 


INLAND  QUARANTINE.  543 

will  always  mean  more  cases  of  the  disease.  Absolute  shielding  of 
cases  of  the  disease  from  the  attacks  of  mosquitoes,  and  the  destruc- 
tion of  the  breeding  places  of  such  mosquitoes,  will  result  in  a  dis- 
appearance of  the  epidemic.  In  fact,  were  all  febrile  cases  of  what- 
ever nature  protected  from  the  attacks  of  the  insects,  and  were  mos- 
quitoes not  allowed  to  propagate  by  careful  and  rigorous  attention  to 
the  accepted  methods  for  their  destruction,  there  need  be  no  spread 
of  the  disease;  but  a  failure  in  any  minute  particular  to  follow  out 
these  two  principles  would  render  any  efforts  for  the  suppression  of 
the  epidemic  largely  negatory. 

It  is  notoriously  a  matter  of  difficulty  to  recognize  cases  of  yellow 
fever  in  a  city  or  locality  where  the  disease  has  not  recently  pre- 
vailed in  epidemic  form,  and  therefore  too  much  stress  cannot  be  laid 
upon  the  necessity  of  screening  all  febrile  cases  until  a  positive  diag- 
nosis can  be  made.  This  applies  equally  to  the  conveyance  of  malarial 
fevers  by  mosquitoes  of  the  genus  Anopheles^  as  to  j^ellow  fever  by  the 
Stegomyia.  Not  only  is  the  mosquito  dangerous  to  the  public  health, 
but  the  malarial  or  yellow  fever  patient  is  prejudicial  to  the  Ano- 
pheles or  Stegomyia  by  infecting  it  prior  to  rendering  it  a  vehicle  for 
the  transmission  of  infection.  The  infection  of  yellow  fever  is  only 
contained  in  the  blood  of  the  yellow-fever  patient  during  the  first 
three  or  four  days  of  the  malady,  and  by  this  time  the  nature  of  the 
illness  can  usually  be  determined. 

THE    CAMPAIGN    OF    PROPHYLAXIS    AGAINST   YELLOW   FEVER 
ON  THE  TEXAS=MEXICAN   BORDER,   1903=04. 

The  epidemic  of  1903  having  ended,  it  became  necessary,  in  view 
of  sanitary  and  climatic  conditions,  to  inaugurate  a  vigorous  cam- 
paign of  prophylaxis  along  the  Texas-Mexican  border  and  in  all 
places  in  Texas  where  the  disease  had  prevailed  during  1903,  to  guard 
against  a  recrudescence  of  the  fever  in  the  spring  of  1904. 

"A  sanitary  inspection  of  the  territory  situated  in  the  triangles 
between  San  Antonio,  Laredo,  Corpus  Christi,  and  Brownsville  was 
inaugurated  and  officers  detailed  to  investigate  the  conditions  along 
the  lines  of  railway  travel  to  detect  any  possible  recrudescence  of  the 
disease.  A  campaign  of  instruction,  showing  the  methods  of  drain- 
age, destruction  of  mosquitoes,  oiling  of  water-containers,  etc.,  and 
the  screening  of  all  yellow  fever  patients,  was  carried  out,  supple- 
mented with  aid  in  fumigation  of  premises,  etc.,  where  requested,  and 
no  doubt  the  generally  satisfactory  condition  of  affaire  at  this  time 


544  TEXT-BOOK:  OF  HYGIENE. 

(September  30,  1904)  is  due  to  this  earl}-  anticipatory  sanitary  cam- 
paign in  aid  of  the  State  and  local  authorities. 

"In  addition  to  the  measures  already  enumerated,  it  was  con- 
sidered advisable  as  a  precautionary  measure  to  prepare,  pack,  and 
store  small  camp  outfits  at  five  points  upon  the  Louisiana-Texas 
border,  thereby  saving  time  in  shipment  should  an  emergency  arise. 
These  camp  outfits  were  accordingly  stored  at  the  selected  points." 

It  is  pertinent  to  add  that  the  measures  were  entirely  successful, 
no  yellow  fever  making  its  appearance  in  Texas  during  the  summer  of 
1904. 

RAILROAD  QUARANTINE  AND  INSPECTION  SERVICE. 

Eailroad  quarantine  and  inspection  service  may  be  described  by 
a  brief  account  of  the  actual  measures  of  this  nature  made  use  of 
during  the  yellow-fever  epidemic  in  Florida,  in  1SS8,  of  which  Camp 
Perry,  just  described,  was  an  important  adjunct.  (For  details,  see 
annual  reports  Marine-Hospital  Service,  1888  and- 1889.) 

The  Governor  of  Florida  made  fipplication  to  the  national  au- 
thorities, July  16th,  for  aid,  and  it  was  determined  to  prevent  further 
spread  of  the  disease  by  disinfecting  all  baggage  from  infected  locali- 
ties before  permitting  its  transportation  into  other  States,  and  by 
enforcing,  upon  all  persons  from  infected  localities  seeking  to  leave 
the  State,  a  probationary  detention  of  ten  days. 

Accordingly,  disinfection  stations  were  established  at  two  points, 
through  which  all  persons  leaving  Florida  by  rail  were  obliged  to  pass. 
One  of  these  was  at  Live  Oak,  in  jSTorthwestern  Florida;  the  other  at 
Way  Cross,  Georgia,  near  the  boundary-line  of  ISTortheastern  Florida. 
The  only  other  means  of  egress  from  the  State  was  from  the  sea- 
ports ;  but  healthy  sea-ports  maintained  a  vigorous  quarantine  against 
people  from  the  infected  districts,  and  infected  sea-ports  were  not 
visited  by  the  steam-ship  lines,  because  their  vessels  would  thereby 
be  made  liable  to  quarantine  detention  at  other  ports.  The  fumiga- 
tion of  baggage  at  Live  Oak  and  Way  Cross  was  accomplished  by 
means  of  box-cars  specially  prepared,  and  subsequently  in  warehouses, 
the  agent  being  sulphur  dioxide. 

Eegarding  persons,  the  inspectors,  properly  uniformed  and  wear- 
ing official  shields,  boarded  the  trains  when  the  latter  arrived  at  the 
inspection  stations,  and  demanded  of  each  passenger  a  certificate, 
showing  where  he  had  been  during  the  previous  ten  days,  Avhich  cer- 
tificate was  considered  valid  only  when  it  bore  the  seal  or  signature  of 
some  officer  of  health,  or  recognized  municipal  authority.     The  in- 


INLAND  QUARAXTTNE.  545 

specters  themselves  were  kept  informed  regarding  all  infected  or  sus- 
pected localities,  and  a  person  coming  from  such  locality  was  either 
made  to  return  to  it  or  given  the  option  of  going  to  the  camp  of  pro- 
bation, there  to  spend  the  ten  days'  period  of  probation  before  being 
allovs^ed  to  enter  other  States. 

This  was  Camp  Perry,  previously  described,  located  38  miles 
south  of  the  Way  Cross  Station,  and  40  miles  north  of  Jacksonville, 
where  the  epidemic  prevailed  chiefly.  All  egress  from  Jacksonville 
was,  perforce,  through  Camp  Perry  and  its  ten  days'  probation. 

This  camp  was  a  means  of  protecting  not  only  other  States,  but 
the  uninfected  portions  of  Florida  itself,  more  particularly  Southern 
Florida,  whose  health  authorities  refused  to  admit  within  their  limits 
the  refugees  from  the  infected  districts  unless  they  had  passed  the 
period  of  probation  at  Camp  Perry.  To  assist  in  this  protection  to 
Southern  Florida,  no  person  was  allowed  to  board  a  south-bound 
train  between  Way  Cross,  on  the  north,  and  Orange  Park,  a  station 
20  miles  south  of  Jacksonville. 

Moreover,  through  south-bound  trains  were  boarded  at  Way  Cross, 
and  all  passengers  compelled  to  furnish  evidence  of  coming  from 
healthful  localities.  The  evidence  consisted  of  certificates  from  local 
authorities,  baggage-checks,  or  railroad-tickets  showing  they  were  pur- 
chased in  the  North,  and  in  some  instances  letters  showing  by  the 
superscription  and  stamps  where  the  person  had  been. 

ISTo  train,  excepting  the  special  government  train,  was  allowed  to 
stop  at  Camp  Perry.  A  government  train  also  carried  those  who  had 
passed  the  period  of  probation  from  Camp  Perry  to  a  point  Syo  miles 
distant,  Folkstone,  where  they  were  transferred  to  a  regular  train 
running  as  far  north  as  Way  Cross,  Ga.,  where  another  transfer  had 
to  be  made  to  a  regular  north-bound  train.  Xo  Florida  passenger- 
car  was  allowed  to  go  north,  and  more  than  1000  baggage-  and  freight- 
cars  were  disinfected  by  government  officers  before  being  allowed  to 
leave  the  State. 

Train-inspection  Service  during  the  Brunswick  Epidemic. — Dur- 
ing the  Brunswick  epidemic  the  following  regulations  for  the  inspec- 
tion of  trains  were  promulgated  and  enforced: — 

"Inspectors  will  allow  none  to  board  a  train,  unless  with  a  cer- 
tificate, between  Way  Cross  and  Savannah. 

"If  certificate  can  be  examined  before  boarding,  without  deten- 
tion to  train,  it  must  be  done,  and  those  which  are  unsatisfactory  will 
not  be  allowed  to  board. 

"After  boarding,  the  certificate  and  the  person  must  be  carefully 


546  TEXT-BOOK  OF  HYGIENE. 

examined  and  the  inspector  assure  himself  that  the  passenger  is  not 
recently  from  Jesup  or  any  infected  locality. 

"If  the  passenger  is  known  to  be  a  recent  resident  of  Jesup  or 
any  infected  locality,  or  to  have  been  in  such  place  during  the  past 
two  (2)  weeks,  he  will  not  be  allowed  to  board,  even  if  he  has  a  cer- 
tificate, o 

"If,  after  boarding,  either  the  certificate  or  the  examination  of 
passengers  is  not  satisfactory,  the  passenger  will  be  turned  over  to 
the  city  authorities  at  Way  Cross  or  Savannah,  or  at  the  place  where 
he  desires  to  stop.  If  between  these  places,  the  facts  to  be  noted  and 
reported. 

"A  record  will  be  kept  of  the  names  of  all  passengers  inspected, 
name  of  signer  of  certificate  and  his  rank,  date  of  inspection,  date  of 
certificate,  and  place  of  boarding  train ;  and  where  passenger  is  bound 
and  what  disposition  is  made  of  him,  whether  passed  or  turned  over 
to  local  authorities;   also  any  other  facts  worth  notice. 

"Inspectors  will  aid  local  quarantine  authorities  in  any  way  in 
their  power  consistent  with  their  duties,  and  give  them  any  informa- 
tion, obeying  all  local  quarantine  regulations.  Inspectors  report  to 
Surgeon  Carter,  United  States  Marine-Hospital  Service,  or  A.  P. 
English,  M.D." 

The  methods  of  railroad  quarantine  may  also  be  studied  in  a 
review  of  the  action  taken  to  prevent  the  introduction  of  small-pox 
into  the  United  States  from  Canada,  where  it  prevailed  extensively  in 
the  fall  and  winter  of  1885,  and  January  and  February,  1886. 

The  following  regulations  were  issued  by  the  Surgeon-General  of 
the  Marine-Hospital  Service,  October  10,  1885 : — 

"The  act  approved  April  29,  1878,  entitled  "An  act  to  prevent 
the  introduction  of  contagious  or  infectious  diseases  into  the  United 
States,''  provides  that  no  vessel  or  vehicle  coming  from  any  foreign 
port  or  country  where  any  contagious  or  infectious  disease  exists,  or 
any  vessel  or  vehicle  conveying  persons,  merchandise,  or  animals 
affected  with  any  contagious  disease,  shall  enter  any  port  of  the  United 
States,  or  pass  the  boundary-line  between  the  United  States  and  any 
foreign  country,  except  in  such  manner  as  may  be  prescribed  under 
said  act. 

"Attention  is  now  directed  to  the  prevalence  of  the  contagious 
and  infectious  disease  of  small-pox  in  Montreal  and  other  places  in  the 
Dominion  of  Canada,  and  the  law  referred  to  is  held  to  apply  alike 
to  trains  of  cars  and  other  vehicles  crossing  the  border,  and  to  vessels 
entering  ports  on  the  northern  frontier. 


INLAND  QUARANTINE.  547 

"Because,  therefore,  of  the  danger  which  attaches  to  the  trans- 
portation of  persons  and  baggage,  and  articles  of  merchandise,  or  ani- 
mals, from  the  infected  districts,  the  following  regulations  are  framed, 
under  the  direction  of  the  Secretary  of  the  Treasury,  and  subject  to 
the  approval  of  the  President,  for  the  protection  of  the  health  of  the 
people  of  the  United  States  against  the  danger  referred  to : — 

"1.  Until  further  orders  all  vessels  arriving  from  ports  in  Canada, 
and  trains  of  cars  and  other  vehicles  crossing  the  border-line,  must 
be  examined  by  a  medical  inspector  of  the  Marine-Hospital  Service 
before  they  will  be  allowed  to  enter  the  United  States,  unless  provision 
shall  have  been  made  by  State  or  municipal  quarantine  laws  and  regu- 
lations for  such  examination. 

"2.  All  persons  arriving  from  Canada,  by  rail  or  otherwise,  must 
be  examined  by  such  medical  inspector  before  they  will  be  allowed  to 
enter  the  United  States,  unless  provision  has  been  made  for  such 
examination. 

"3.  All  persons  coming  from  infected  districts,  not  giving  satis- 
factory evidence  of  protection  against  small-pox,  will  be  prohibited 
from  proceeding  into  the  United  States  until  after  such  period  as  the 
medical  inspector,  the  local  quarantine,  or  other  sanitary  officer  duly 
authorized,  may  direct. 

"4.  The  inspectors  will  vaccinate  all  unprotected  persons,  who 
desire  or  are  willing  to  submit  to  vaccination,  free  of  charge.  Any 
such  person  refusing  to  be  vaccinated  shall  be  prevented  from  entering 
the  United  States. 

"5.  All  baggage,  clothing,  and  other  effects,  and  articles  of  mer- 
chandise, coming  from  infected  districts,  and  liable  to  carry  infection, 
or  suspected  of  being  infected,  will  be  subjected  to  thorough  disinfec- 
tion. 

"6.  All  persons  showing  evidence  of  having  had  small-pox  or 
varioloid,  or  who  exhibit  a  well-defined  mark  of  recent  vaccination, 
may  be  considered  protected;  but  the  wearing-apparel  and  baggage 
of  such  protected  persons  who  may  come  from  infected  districts,  or 
have  been  exposed  to  infection,  will  be  subjected  to  thorough  disin- 
fection as  provided. 

"7.  Customs  officers  and  United  States  medical  inspectors  will 
consult  and  act  in  conjunction  with  authorized  State  and  local  health 
authorities  so  far  as  may  be  practicable,  and  unnecessary  detention 
of  trains  or  other  vehicles,  persons,  animals,  baggage,  or  merchandise, 
will  be  avoided  so  far  as  may  be  consistent  with  the  prevention  of  the 


548  TEXT-BOOK  OF  HYGIENE. 

introduction  of  disease  dangerous  to  tlie  public  healtli  into  the  United 
States. 

"8.  Inspectors  will  make  full  weekl}^  reports  of  services  performed 
under  this  regulation. 

"9.  As  provided  in  Section  5  of  said  act,  all  quarantine  officers 
or  agents  acting  under  any  State  or  municipal  system,  upon  the  appli- 
cation of  the  respective  State  or  municipal  authorities,  are  empowered 
to  enforce  the  provisions  of  these  regulations,  and  are  hereby  author- 
ized to  prevent  the  entrance  into  the  United  States  of  any  vessel  or 
vehicle,  person,  merchandise,  or  animals  prohibited  under  the  act 
aforesaid. 

"10.  In  the  enforcement  of  these  regulations  there  shall  be  no 
interference  with  any  quarantine  laws  or  regulations  existing  under 
or  to  be  provided  for  by  any  State  or  municipal  authority." 

The  following  are  the  special  instructions  for  the  guidance  of 
sanitary  inspectors,  issued  by  Surgeon  H.  W.  Austin,  in  charge  of  the 
inspection  service  on  the  Canadian  frontier  from  Buffalo,  N.  Y.,  to 
the  Atlantic  coast  during  the  epidemic  above  referred  to  (see  Marine- 
Hospital  Eeport,  1886)  :— 

Eegulations  for  Sanitary  Inspectors, 

"The  following  instructions  will  be  observed  by  the  sanitary  in- 
spector on  the  following-mentioned  railroads  crossing  the  United 
States  boundary-line — viz.,  the  Grand  Trunk  Railway,  at  Eouse's 
Point,  N.  Y.,  and  Island  Pond,  Vt. ;  the  Passumpsic  Railroad,  at 
iSTewport,  Yt. ;  the  Central  Vermont  Railroad,  at  Uighgate  Springs 
or  Saint  Albans;  the  Canada  Atlantic,  at  Rouse's  Point,  N.  Y.,  and 
the  Southeastern  Railway,  at  Richford,  Yt. : — 

"All  persons  bound  for  the  United  States  coming  from  Montreal, 
or  other  places  in  Canada  where  small-pox  prevails,  must  produce 
satisfactory  evidence  to  the  inspector  that  they  are  protected  by  a 
recent  vaccination,  or  submit  to  this  operation  before  they  are  allowed 
to  cross  the  boundary-line. 

"Inspectors  will  vaccinate  all  unprotected  persons  free  of  charge. 

"Persons  coming  from  Montreal,  or  suburban  villages,  will  be 
carefully  questioned  as  to  their  residence,  whether  small-pox  has 
occurred  in  their  families,  or  whether  they  have  been  in  contact  with 
the  disease. 

"Inquiries  should  also  be  made  relative  to  their  baggage,  whether 
it  consists  of  bedding,  household  goods,  etc.,  likely  to  be  infected ;  and 


INLAND  QUARANTINE.  549 

if  any  person  or  article  of  baggage  is  considered  by  the  inspector  in- 
fected or  likely  to  introduce  the  disease  into  the  country,  he  or  it 
should  not  be  permitted  to  cross  the  line  into  the  United  States. 

"You  may  consider  persons  protected  who  may  show  evidence  of 
having  had  the  small-pox  or  varioloid,  or  who  exhibit  a  well-defined 
mark  of  vaccination.  Accept  as  evidence  of  protection  a  certificate 
from  any  physician  in  good  standing  that  the  person  presenting  the 
same  has  been  successfully  vaccinated.  Should  3'ou  doubt  the  validity 
or  authenticity  of  the  certificate,  you  may  refuse  any  such  person 
presenting  the  same  the  privilege  of  crossing  the  border  unless  he 
submits  to  vaccination.  Baggage  known  to  have  come  from  any  in- 
fected district,  and  believed  to  be  infected,  will  be  thoroughly  fumi- 
gated with  sulphur  at  Eouse's  Point,  Saint  Albans,  Richford,  ISTew- 
port,  and  Island  Pond. 

'Weekly  reports  should  be  made  to  Surgeon  H.  W.  Austin, 
United  States  Marine-Hospital  Service,  Burlington,  Vt.,  of  the  num- 
ber of  trains  inspected,  number  of  persons  examined,  number  of  per- 
sons vaccinated,  number  of  pieces  of  baggage  fumigated,  and  any 
other  information  relative  to  services  performed  by  the  inspector.'' 

It  will  be  observed  that  all  the  railroads,  five  in  number,  over 
which  passengers  or  freight  might  be  brought  direct  from  Canada 
into  the  'New  England  States,  were  guarded. 

Besides  the  line  commanded  by  Surgeon  Austin  (Atlantic  coast 
to  Buffalo),  another  line  was  under  the  direction  of  Passed  Assistant 
Surgeon  Wheeler,  at  points  east  of  Buffalo,  and  still  another  on  the 
Michigan  frontier,  under  command  of  Surgeon  W.  H.  Long.  These 
lines  were  established  at  the  request  and  with  the  co-operation  of  the 
authorities  of  the  respective  States.  Thirty-six  inspectors  were  em- 
ployed at  37  stations,  who  examined  49,631  persons  on  railroad-trains, 
vaccinated  16,547,  and  detained  or  sent  back  603.  The  contents  of 
more  than  7000  pieces  of  baggage  were  disinfected.  The  measures 
taken  were  successful. 

In  1893,  at  a  time  when  there  was  imminent  danger  that  cholera 
might  be  introduced  into  the  sea-board  cities  of  the  United  States 
and  carried  by  immigrants  to  the  far  West  and  the  interior  cities  and 
towns,  a  most  carefully  formulated  plan  of  railroad  medical  inspec- 
tion of  immigrants  was  drawn  up;  and  while  it  was,  fortunately, 
never  necessary  to  carry  out  Ihe  provisions  made  at  the  time,  the  fol- 
lowing regulations  will  m-gII  show  the  scope  and  general  design  of  the 
protective  and  restrictive  measures  contemplated: — 


550  TEXT-BOOK  OF  HYGIENE. 

Eailroad  Medical  Inspection  of  Immigrants. 

Treasuey  Department, 
Office  of  the  Supervising  Surgeon-General  United  States 
Marine-Hospital  Service, 

Washington,  August  23,  1893. 

Instructions  for  the  Guidance  of  Medical  Officers  of  the  Marine-Hos- 
pital Service,  Sanitary  Inspectors,  and  other's  concerned. 

1.  One  or  more  medical  inspectors  shall  accompany  immigrants 
from  the  point  of  departure  of  each  immigrant  train,  and  shall  im- 
mediately commence  making  a  careful  inspection  of  every  passenger — ■ 
man,  woman,  and  child — upon  the  train.  This  inspection  shall  consist 
in  identifying  each  passenger  with  the  health  card  or  cards  he  or  she 
may  hold,  and  satisfying  himself  as  to  the  health  of  each  person  at  the 
time  of  said  inspection.  He  shall  pass  through  the  train  once  every 
hour  or  oftener,  if  he  has  reason  to  believe  any  person  is  suffering 
with  diarrhcea  or  other  symptoms  of  cholera. 

2.  The  railroad  companies  will  be  expected  to  furnish  earth- 
closets,  which  should  be  used,  and  the  regular  closets  of  the  car  are 
to  be  locked.  These  earth-closets  shall  be  destroyed,  before  the  train 
reaches  it  destination,  at  such  points  as  the  railroad  officials  shall 
designate.  It  shall  be  the  duty  of  the  inspector  to  see  that  the  earth- 
closets  are  kept  clean  and  frequently  disinfected,  and  the  cars  prop- 
erly ventilated  and  free  from  all  offensive  odors  and  dirt. 

3.  He  shall,  upon  the  least  suspicion  of  cholera  among  the  im- 
migrants, have  the  suspected  person  or  persons  immediately  removed 
to  the  hospital  car  at  the  rear  of  the  train,  disinfect  all  ejecta,  and 
take  every  precaution  possible  to  prevent  the  spread  of  the  disease 
among  the  passengers  by  thoroughly  disinfecting  that  portion  of  the 
car  occupied  by  the  suspects,  the  simplest  means  for  this  purpose  being 
a  solution  of  bichloride  of  mercury  in  the  proportion  of  1  to  800. 

4.  The  inspectors  will  at  once  notify  the  conductor  of  the  train 
upon  the  first  appearance  of  a  suspicious  case,  in  order  that  the  hos- 
pital car  may  be  switched  off  at  the  first  designated  switch,  and  the 
health  officer  of  the  county  in  which  said  switch  is  located  be  imme- 
diately notified  to  take  charge  of  this  car. 

5.  It  is  expected  that  the  railroads  will  furnish  a  car  for  hospital 
purposes,  in  which  the  seats  can  be  readily  converted  into  beds  suit- 
able for  the  care  of  the  sick.  The  necessary  bedding  will  be  furnished 
by  the  United  States  Marine-Hospital  Service. 

6.  Disinfectants,  consisting  of  packages  of  bichloride  of  mercury 


INTERSTATE  QUARANTINE.  551 

and  an  alkali,  will  be  furnished  the  medical  inspector  in  proper  quan- 
tities for  adding  to  a  two-gallon  wooden  bucket  of  water ;  also  a  quan- 
tity of  carbolic  acid  in  solution  and  other  approved  disinfectants. 
Each  hospital  car  shall  be  equipped  with  a  dozen  two-gallon  wooden 
buckets  for  holding  disinfecting  fluids,  half  a  dozen  mops,  one  or  more 
hand  force-pumps  with  rose  sprinklers,  one  or  more  commodes  and 
bed-pans,  half  a  dozen  eight-ounce  hard-rubber  sj^ringes,  half  a  dozen 
tumblers,  one  dozen  rubber  sheets,  and  one  dozen  feeding-cups  for 
administering  medicine.  There  shall  also  be  furnished  an  oil-stove 
for  heating  water,  and  several  tin  boilers  and  tin  cups. 

7.  Medical  supplies,  etc.,  consisting  of  tannic  acid,  hydrarg.  chlo- 
ridum  mite,  tincture  of  opium,  mustard  or  mustard  papers,  chloro- 
form or  ether  sulph.,  whisky,  brandy,  and  one  or  more  hypodermic 
syringes;  also  supply  of  Squibb's  Diarrhoea  Mixture  for  checking 
looseness  of  the  bowels  or  premonitory  diarrhoea. 

Walter  Wyman, 
Supervising  Surgeon-General. 

INTERSTATE  QUARANTINE. 

The  general  principles  governing  interstate  quarantine  are  the 
same  as  those  pertaining  to  the  maritime  and  foreign  quarantines, 
with  the  exception  that,  instead  of  dealing  with  ships  as  the  media 
of  transportation,  we  must  deal  with  trains  on  railroads,  lines  of 
stage-coaches,  and  steam-boats  plying  on  the  inland  waters  of  the 
United  States.  The  principles  are  almost  sufficiently  elaborated  in 
the  previous  sections  on  train  inspection  in  the  case  of  yellow-fever 
epidemics,  and  the  precautions  which  were  under  consideration  for  the 
prevention  of  the  spread  of  cholera  by  means  of  emigrant  trains. 

An  important  matter  is  the  one  of  notification.  It  will  be  seen, 
by  a  study  of  the  regulations  for  interstate  quarantine  which  follow, 
that  State  and  municipal  health  officers  are  requested  to  notify  the 
Supervising  Surgeon-General  of  the  appearance  of  any  of  the  quar- 
antinable  diseases  in  their  States  or  localities,  thus  enabling  appro- 
priate measures  to  be  taken  to  prevent  their  spread  without  the  loss 
of  valuable  time,  for  time  in  the  management  of  epidemics  is  of  the 
utmost  importance.  Many  an  epidemic  which  has  assumed  vast  pro- 
portions would,  if  recognized  in  time,  have  been  capable  of  easy  man- 
agement and  of  being  confined  to  the  seat  of  its  first  outbreak.  It  is 
always  comparatively  easy  to  confront  an  open  enemy;  it  is  the  in- 
sidious spread  of  disease,  either  unrecognized  or  concealed  for  reasons 


552  TEXT-BOOK  OF  HYGIENE. 

of  business  polic}^,  that  causes  delay  in  the  inception  of  preventive 
measures,  and  is  most  to  be  dreaded  from  a  sanitary  standpoint. 

The  following  are  the  regulations  prepared  in  the  Marine-Hos- 
pital Bureau  to  prevent  the  introduction  of  contagious  diseases  into 
one  State  or  Territory  or  the  District  of  Columbia  from  another  State 
or  Territory  or  District  of  Columbia.  It  is  expected  that  additional 
regulations  will  be  promulgated  from  time  to  time  as  circumstances 
demand : — 

Interstate  Quaeantine. 

article  i. quarantine  diseases. 

1.  Tor  the  purpose  of  these  regulations  the  quarantinable  diseases 
are  cholera  (cholerine),  yellow  fever,  small-pox,  typhus  fever,  leprosy, 
and  plague. 

ARTICLE   II. — NOTIFICATION. 

1.  State  and  municipal  health  officers  should  immediately  notify 
the  Supervising  Surgeon- General  of  the  United  States  Marine-Hos- 
pital Service,  by  telegi-aph  or  by  letter,  of  the  existence  of  any  of  the 
above-mentioned  quarantinable  diseases  in  their  respective  States  or 
localities. 

ARTICLE   III. — GENERAL   REGULATIONS. 

1.  Persons  suffering  from  a  quarantinable  disease  shall  be  iso- 
lated until  no  longer  capable  of  transmitting  the  disease  to  others. 
Persons  exposed  to  the  infection  of  a  quarantinable  disease  shall  be 
isolated,  under  observation,  for  such  a  period  of  time  as  may  be  nec- 
essary to  demonstrate  their  freedom  from  the  disease. 

All  articles  pertaining  to  such  persons,  liable  to  convey  infection, 
shall  be  disinfected  as  hereinafter  provided. 

2.  The  apartments  occupied  by  persons  suffering  from  quaran- 
tinable disease,  and  adjoining  apartments,  when  deemed  infected, 
together  with  articles  therein,  shall  be  disinfected  upon  the  termina- 
tion of  the  disease. 

3.  Communication  shall  not  be  held  with  the  above-named  per- 
sons and  apartments,  except  under  the  direction  of  a  duly-qualified 
officer. 

4.  All  cases  of  quarantinable  disease,  and  all  cases  suspected  of 
belonging  to  this  class,  shall  be  at  once  reported  by  the  physician  in 
attendance  to  the  proper  authorities. 

5.  No  common  carrier  shall  accept  for  transportation  any  person 


INTERSTATE  QUARANTINE.  553 

suffering  with  a   quarantinable  disease,  nor  any  infected  article  of 
clothing,  bedding,  or  personal  property. 

Bodies  of  persons  who  have  died  from  any  of  the  said  diseases 
shall  not  be  transported  save  in  hermetically-sealed  coffins,  and  by  the 
order  of  the  State  or  local  health  officer. 

6.  In  the  event  of  the  prevalence  of  small-pox,  all  persons  exposed 
to  the  infection,  who  are  not  protected  hy  vaccination  or  a  previous 
attack  of  the  disease,  shall  be  at  once  vaccinated  or  isolated  for  a  period 
of  fourteen  days. 

7.  During  the  prevalence  of  cholera,  all  the  dejecta  of  cholera 
patients  shall  be  at  once  disinfected,  as  hereinafter  provided,  to  pre- 
vent possible  contamination  of  the  food-  and  water-supply. 

ARTICLE  IV. — YELLOW  FEVER. 

In  addition  to  the  foregoing  regulations  contained  in  Article  I, 
the  following  special  provisions  are  made  with  regard  to  the  preven- 
tion of  the  introduction  and  spread  of  5'ellow  fever: — 

1.  Localities  infected  with  yellow  fever,  and  localities  contiguous 
thereto,  should  be  depopulated  as  rapidly  and  as  completely  as  pos- 
sible, so  far  as  the  same  can  be  safely  done ;  persons  from  non-infected 
localities,  and  who  have  not  been  exposed  to  infection,  being  allowed 
to  leave  without  detention.  Those  who  have  been  exposed,  or  who 
came  from  infected  localities,  shall  be  required  to  undergo  a  period  of 
detention  and  observation  of  ten  days,  from  the  date  of  last  exposure, 
in  a  camp  of  probation  or  other  designated  place. 

Clothing  and  other  articles  capable  of  conveying  infection  shall 
not  be  transported  to  non-infected  localities  without  disinfection,  i.e., 
inspection  to  determine  the  presence  of  possibly  infected  mosquitoes, 
and  appropriate  measures  of  fumigation  to  destroy  them. 

2.  Persons  who  have  been  exposed  may  be  permitted  to  proceed 
without  detention  to  places  willing  to  receive  them,  and  incapable  of 
becoming  infected,  when  arrangements  have  been  perfected  to  the 
satisfaction  of  the  proper  health  officer  to  insure  their  detention  in 
said  places  for  a  period  of  ten  days. 

3.  The  suspects  who  are  isolated  under  the  provisions  of  para- 
graph 1,  Article  III,  shall  be  kept  free  from  all  possibility  of  infection. 

4.  So  far  as  possible  the  sick  should  be  removed  to  a  central  loca- 
tion for  troatment. 

5.  Buildings  in  which  yellow  fever  has  occurred,  and  localities 
believed  to  be  infected  with  said  disease,  must  be  disinfected  as  thor- 
oughly as  possible. 


554  TEXT-BOOK  OF  HYGIENE. 

6.  As  soon  as  the  disease  becomes  epidemic,  the  railroad-trains 
carrying  persons  allowed  to  depart  from  the  city  or  place  infected  with 
yellow  fever  shall  be  under  medical  supervision. 

7.  Common  carriers  from  the  infected  districts,  or  believed  to  be 
carrying  persons  and  effects  capable  of  conveying  infection,  shall  be 
subject  to  sanitary  inspection,  and  such  persons  and  effects  shall  not 
be  allowed  to  proceed,  except  as  provided  for  by  paragraph  2. 

8.  At  the  close  of  an  epidemic  the  houses  where  sickness  has 
occurred,  and  the  contents  of  the  same,  and  houses  and  contents  that 
are  presumably  infected,  shall  be  disinfected  as  hereinafter  prescribed. 

ARTICLE   V. DISINFECTION". 

For  Cholera. 

1.  The  dejecta  and  vomited  matters  of  cholera  patients  shall  be 
received  into  vessels  containing  an  acid  solution  of  bichloride  of  mer- 
cury (bichloride  of  mercury,  1  part;  hydrochloric  acid,  2  parts; 
water,  1000  parts)  or  other  efficient  germicidal  agent. 

2.  All  bedding,  clothing,  and  wearing-apparel  soiled  by  the  dis- 
charges of  cholera  patients  shall  be  disinfected  by  one  or  more  of  the 
following  methods : — 

(a)  By  complete  immersion  for  thirty  minutes  in  one  of  the 
above-named  disinfecting  solutions. 

(&)  By  boiling  for  fifteen  minutes,  all  articles  to  be  completely 
submerged. 

(c)  By  exposure  to  steam  at  a  temperature  of  100°  to  102°  C. 
for  thirty  minutes  after  such  temperature  is  reached. 

3.  Any  woodwork  or  furniture  contaminated  by  cholera  dis- 
charges shall  be  disinfected  by  thorough  washing  with  a  germicidal 
solution  as  provided  in  paragraph  1,  Article  V. 

For  Yellow  Fever. 

4.  Apartments  infected  by  occupancy  of  patients  sick  with  yellow 
fever  shall  be  disinfected  by  one  or  more  of  the  following  methods : — 

{a)  By  thorough  washing  with  one  of  the  germicidal  solutions 
mentioned.  If  apprehension  is  felt  as  to  the  poisonous  effects  of  the 
mercury,  the  surfaces  may,  after  two  hours,  be  washed  with  clear 
water. 

(&)  Thorough  washing  with  a  5-per-cent.  solution  of  pure  car- 
bolic acid. 


INTERSTATE  QUARAXTIXE.  555 

(c)  By  sulphur  dioxide,  twenty-four  to  forty-eight  hours'  expo- 
sure, the  apartments  to  be  rendered  as  air-tight  as  possible. 

5.  Bedding,  wearing-apparel,  carpets,  hangings,  and  draperies 
infected  by  yellow  fever  shall  be  disinfected  by  one  of  the  following 
methods : — 

(a)  By  exposure  to  steam  at  a  temperature  of  100°  to  103°  C. 
for  thirty  minutes  after  such  temperature  is  reached. 

(h)  By  boiling  for  fifteen  minutes,  all  articles  to  be  completely 
submerged. 

(c)  By  thorough  saturation  in  a  solution  of  bichloride  of  mer- 
cury, 1  to  1000,  the  articles  being  allowed  to  dry  before  washing. 

Articles  injured  by  steam  (rubber,  leather,  containers,  etc.),  to 
the  disinfection  of  which  steam  is  inapplicable,  shall  be  disinfected 
by  thoroughly  wetting  all  surfaces  with  (a)  a  solution  of  bichloride 
of  mercury  1  to  800,  or  (&)  a  5-per-cent.  solution  of  carbolic  acid,  the 
articles  being  allowed  to  dry  in  the  open  air  prior  to  being  washed 
with  water,  or  (c)  by  exposure  to  sulphur  fumigation  in  an  apart- 
ment air-tight,  or  as  nearly  so  as  possible. 

(Recent  investigations  have  proved  that  in  disinfection  for  yellow 
fever  less  attention  need  be  paid  to  fomites,  but  more  to  the  exter- 
mination of  mosquitoes.) 

For  Small-pox. 

6.  Apartments  infected  by  small-pox  shall  be  disinfected  by  one 
or  both  of  the  following  methods : — 

(a)  Exposure  to  sulphur  dioxide  for  twenty-four  to  forty-eight 
hours. 

(b)  Washing  with  a  solution  of  bichloride  of  mercury  1  to  1000, 
or  a  5-per-cent.  solution  of  pure  carbolic  acid. 

7.  Clothing,  bedding,  and  articles  of  furniture  exposed  to  the 
infection  of  small-pox  shall  be  disinfected  by  one  or  more  of  the  fol- 
lowing methods : — 

(a)  Exposure  to  sulphur  dioxide  for  twenty-four  to  forty-eight 
hours. 

(h)  Immersion  in  a  solution  of  Inchloride  of  mercury  1  to  1000, 
or  a  o-per-cent.  solution  of  pure  carbolic  acid. 

(x)  Exposure  to  steam  at  a  temperature  of  100°  to  102°  C.  for 
thirty  minutes  after  such  temperature  is  reached. 

(d)  Boiling  for  fifteen  minutes,  the  articles  to  be  completely 
submerged. 


556  TEXT-BOOK  OF  HYGIENE. 

For  Typhus  Fever. 

8.  Apartments  infected  by  typhus  fever  shall  be  disinfected  by 
one  or  both  of  the  following  methods : — 

(a)  Exposure  to  sulphur  dioxide  for  twenty-four  to  forty-eight 
hours. 

(&)  Washing  with  a  solution  of  bichloride  of  mercury  1  to  1000, 
or  a  5-per-cent.  solution  of  pure  carbolic  acid. 

9.  Clothing,  bedding,  and  articles  of  furniture  exposed  to  the 
infection  of  typhus  fever,  shall  be  disinfected  by  one  or  more  of  the 
following  methods : — 

(a)  Exposure  to  sulphur  dioxide  for  twenty-four  to  forty-eight 
hours. 

(&)  Immersion  in  a  solution  of  bichloride  of  mercury  1  to  1000, 
or  a  5-per-cent.  solution  of  pure  carbolic  acid. 

(c)  Exposure  to  steam  at  a  temperature  of  100°  to  102°  C.  for 
thirty  minutes  after  such  temperature  is  reached. 

{d)  Boiling  for  fifteen  minutes,  the  articles  to  be  completely  sub- 
merged. 

(Lately  fumigation  with  formaldehyde  gas  has  taken  the  place 
of  sulphur  dioxide.) 

MUNICIPAL  QUARANTINE. 

It  is  now  generally  conceded  that  a  small  number  of  cases  of 
certain  ones  of  the  quarantinable  diseases  may  exist  in  a  city  of  con- 
siderable size,  without  giving  rise  to  serious  apprehension,  if  intelli- 
gent and  vigorous  measures  for  the  prevention  of  its  spread  are  taken, 
and  if  scientific  measures  for  the  isolation  of  patients,  the  surveillance 
of  those  exposed  to  infection,  and  the  disinfection  of  apartments  and 
articles  infected  are  carried  out.  It  is  regarded  as  very  important 
that  the  sick  should  be  removed  to  centrally-located  hospital  estab- 
lishments for  treatment,  thus  increasing  ease  of  management  and 
administration,  and  diminishing  the  number  of  foci  of  infection.  The 
surveillance  of  those  exposed  to  infection  should,  in  general,  be  for  a 
period  of  time  equal  to  the  usual  period  of  incubation  of  the  disease 
to  which  they  have  been  exposed.  In  the  case  of  small-pox  it  may 
be  unnecessary  at  times  to  detain  the  suspects  the  full  period  of  in- 
cubation, provided  they  are  vaccinated  and  their  clothing  and  per- 
sonal effects  are  rendered  safe  by  efficient  disinfection.  They  should, 
however,  be  kept  under  observation. 

For  the  suppression  of  small-pox  in  cities  in  which  it  has  made 


MUNICIPAL  QUARANTINE.  557 

its  appearance,  and  in  which  it  threatens  to  become  epidemic,  the 
following  suggestions,  made  by  the  health  authorities  of  the  North- 
west, will  undoubtedly  prove  of  value: — 

1.  The  city  should  be  divided  into  districts  containing  not  more 
than  10,000  people. 

2.  Each  district  should  be  placed  under  the  supervision  of  a  com- 
petent medical  inspector  with  necessary  assistants  (a)  to  make  a 
house-to-house  inspection;  (b)  to  successfully  vaccinate,  within  the 
shortest  possible  time,  all  persons  who  have  not  been  vaccinated  dur- 
ing the  outbreak,  the  first  vaccination  to  be  completed  within  seven 
days;  (c)  to  properly  disinfect  all  houses  and  their  contents  where 
small-pox  occurs. 

3.  Necessary  means  and  appliances  for  efficient  disinfection  of 
materials,  premises,  etc.,  should  be  provided  as  the  exigencies  of  each 
district  may  require. 

4.  Each  case  of  small-pox  should  be  immediately  removed  to  a 
suitably  constructed  and  properly  equipped  and  officered  isolation  hos- 
pital. 

5.  Except  in  extreme  cold  weather,  hospital  tents,  as  prescribed 
in  the  United  States  Army  Eegulations,  floored  and  warmed,  are 
preferable  to  the  average  hospital  or  private  dwelling,  and  increase 
the  chances  of  recovery  of  the  patients.  Cases  of  small-pox  neces- 
sarily retained  in  their  own  homes  should,  with  their  attendants,  be 
rigidly  isolated  during  the  period  of  danger,  and  physicians  visiting 
such  patients  professionally  should  be  subject  to  such  regulations  as 
may  be  prescribed  by  the  local  health  officer. 

6.  Persons  exposed  to  small-pox  contagion  should  be  immediately 
vaccinated  and  kept  under  observation  for  not  less  than  fourteen  days 
from  time  of  last  exposure. 

7.  It  is  the  sense  of  this  Conference  that  unless  such  measures 
are  enforced,  it  will  be  necessary  for  neighboring  cities  and  States  to 
exclude  all  persons  from  such  city  who  are  not  protected  against  small- 
pox by  recent  vaccination,  and  to  require  proper  disinfection  of  all 
clothing,  baggage,  and  merchandise  capable  of  conveying  small-pox 
infection. 

The  subject  of  municipal  quarantine  naturally  suggests  a  sub- 
division of  the  subject,  viz.,  domiciliary  quarantine,  or  the  exercise  of 
restrictive  measures  against  a  particular  house  or  part  of  a  house  on 
account  of  the  occurrence  of  a  quarantinable  disease  within  its  limits. 
These  can  best  be  accomplished  by  the  stationing  of  guards  to  see  that 
none  enter  or  leave  llio  infected  premises  except  those  necessary  to 


558  TEXT-BOOK  OF  HYGIENE. 

care  for  the  sick,  viz.,  physicians  and  nurses.  All  intercourse  between 
the  outside  world  and  the  house  under  quarantine  should  be  carried 
on  by  messengers  who  should  not  be  allowed  to  enter  the  premises, 
but  who  should  report  to  the  guards. 

It  would  be  most  desirable  that  the  physicians  and  nurses,  on 
leaving  the  premises,  should  practice  personal  disinfection  of  hands, 
at  least;  though,  of  course,  it  would  be  better  if,  in  addition  to  this, 
a  change  into  sterile  clothing  Avere  made  prior  to  coming  into  contact 
with  the  public. 

It  goes  without  saying  that  the  room  of  the  patient  should  be 
absolutely  closed  to  the  ingress  of  all  save  the  physicians  and  nurses, 
and  it  is  a  practice  of  considerable  value  to  provide  all  room-openings 
with  curtains  or  hangings,  which  are  to  be  kept  constantly  wet  with 
a  germicidal  solution.  The  dejecta,  vomited  matter,  and  sputum 
should  be  promptly  disinfected  according  to  circumstances.  When 
the  disease  has  terminated,  the  house  or  aj^artments  are  to  be  thor- 
oughly disinfected  by  one  of  the  methods  prescribed  in  the  regula- 
tions, the  method  chosen  being  adapted  to  the  disease  which  has  pre- 
vailed. For  the  purposes  of  municipal  disinfection  the  Marine-Hos- 
pital Service  has  had  constructed  portable  apparatus  for  the  use  of 
steam  and  sulphur,  which  are,  in  effect,  the  same  apparatus  as  have 
been  previously  described  in  this  article,  modified  to  meet  their  special 
requirements. 

An  important  factor  in  the  measures  taken  to  suppress  any  epi- 
demic disease  is  a  house-to-house  inspection,  to  ascertain  the  actual 
number  of  cases  existing.  Whether  this  inspection  should  include  the 
whole  city,  or  only  the  infected  district,  is  a  matter  for  the  exercise 
of  judgment;  but,  when  required,  the  inspections  should  be  made  at 
intervals  corresponding  with  the  usual  periods  of  incubation  of  the 
disease  under  observation. 

A  very  important  field  for  the  exercise  of  municipal  and  domi- 
ciliary quarantine  is  furnished  by  those  contagious  and  infectious 
diseases  which,  while  causing  large  mortality,  seldom  prevail  in  epi- 
demic form,  viz.,  measles,  scarlet  fever,  diphtheria,  and  tuberculosis. 

MEASLES. 

Measles  may  be  dismissed  with  a  few  words.  The  course  of  the 
disease,  uncomplicated,  is  usually  so  benign,  especially  in  children, 
that  all  that  is  necessary  is  isolation.  At  the  conclusion  of  the  case 
or  cases  the  apartment  should  be  well  aired,  and  it  may  be  advisable 


DIPHTHERIA  AND  SCARLET  FEVER.  559 

to  subject  the  room  and  the  contents,  bedding,  and  clothing  to  fumi- 
gation by  sulphur  or  formaldehyde. 

DIPHTHERIA  AND  SCARLET  FEVER. 

With  diphtheria  and  scarlet  fever  the  conditions  are  far  different. 
The  diseases  are  virulent:  the  infection  is  subtle,  and  their  spread 
very  much  to  be  dreaded.  Vigorous  effort  alone  can  prevent  their 
spread.  Dwellings  where  the  disease  prevails  must  be  placarded,  spe- 
cial hospitals  should  be  provided,  and  disinfection  should  be  intelli- 
gently performed  by  competent  municipal  authority. 

The  regulations  of  the  Board  of  Health  of  the  District  of  Co- 
lumbia are  given  here,  as  embodying  the  more  recent  practice  in  the 
management  of  these  diseases : — 

Eegulations  to  Prevent  the  Spread  of  Diphtheria  and 
Scarlet  Fever. 

"The  following  regulations,  provided  for  in  the  Act  of  Congress 
approved  December  30,  1890,  are  promulgated  for  the  information 
of  all  concerned  :— 

"The  act  referred  to  provides,  in  Section  2,  'That  it  shall  be  the 
duty  of  the  health  officer,  in  conjunction  with  the  attending  physician, 
to  cause  the  premises  to  be  properly  disinfected,  and  to  issue  the 
necessary  instructions  for  the  isolation  of  the  patient;  in  Section  3, 
'That  it  shall  be  the  duty  of  physicians,  while  in  attendance  upon 
cases  of  scarlet  fever  and  diphtheria,  to  exercise  such  reasonable  pre- 
cautions to  prevent  the  spread  of  the  said  diseases  as  may  be  prescribed 
by  the  health  officer  of  the  District  of  Columbia  in  regulations';  in 
Section  6,  'That  the  word  "regulations,"  as  herein  used,  shall  be  held 
to  mean,  also,  rules,  orders,  and  amendments.' 

"The  term  'scarlet  fever,'  as  applied  in  the  act,  shall  be  held  to 
include  scarlatina,  scarlet  rash,  and  canker  rash,  and  each  and  every 
case  must  be  reported  upon  the  forms  provided. 

"Warning-signs  shall  remain  displayed  on  houses,  in  cases  of 
scarlet  fever,  for  a  period  of  not  less  than  four  weeks,  and  in  cases 
of  diphtheria  for  not  less  than  three  weeks  from  date  of  report  to 
the  health  officer,  and  for  a  longer  period,  unless  report  of  recovery 
by  the  physician  in  attendance  has  been  made. 

"In  cases  of  death,  the  warning-sign  shall  remain  displayed  upon 
premises  for  a  period  of  not  less  than  seven  days,  and  longer,  unless 
the  health  officer  is  satisfied  that  all  proper  means  liuve  been  employed 
for  provontion  of  the  spread  of  tlie  contagion. 


560  TEXT-BOOK  OF  HYGIENE. 

"It  shall  be  the  duty  of  the  householder,-  in  every  case  where  a 
warning-sign  has  been  displayed  from  the  premises  which  he  or  she 
occupies,  to  report  promptly  the  removal  of  such  sign  at  any  time 
within  the  periods  given. 

"It  shall  be  the  like  duty  of  the  physician  in  attendance  to  make 
such  report  to  the  health  officer  of  the  removal  of  warning-signs, 
unless  assured  that  the  report  has  been  made  by  some  one  from  the 
premises  where  the  disease  is  prevailing  or  has  prevailed. 

"It  shall  be  the  duty  of  the  physician  in  attendance  to  report, 
in  every  instance,  on  the  forms  provided,  whether  or  not  children  in 
the  family  or  other  children  in  the  same  building  attend  school,  and 
at  what  school-building  or  buildings. 

"Children  shall  not  be  permitted  to  return  to  school  from  in- 
fected premises,  except  upon  presentation  of  the  proper  certificate 
from  the  health  officer. 

"All  persons  suffering  from  either  diphtheria  or  scarlet  fever  are 
to  be  isolated  in  rooms  as  far  removed  as  possible  from  those  occupied 
by  other  persons  in  the  building,  and  upon  the  top  floor,  where  it  is 
practicable.  No  person,  other  than  the  physician  in  attendance,  the 
examining  official,  and  the  nurse  or  nurses,  shall  be  admitted  to  such 
room  during  the  prevalence  of  the  disease. 

"Every  room  occupied  by  a  patient  suffering  from  either  diph- 
theria or  scarlet  fever  shall  be  cleared  of  all  needless  clothing,  carpets, 
drapery,  and  other  materials  likely  to  harbor  the  poisons  of  the 
disease. 

"Soiled  bed-  and  body-linen  shall  be  immediately  placed  in  ves- 
sels of  water  containing  a  solution  of  bichloride  of  mercury,  chloride 
of  zinc,  or  other  suitable,  disinfectant. 

"Excremental  discharges  from  the  patient  shall  be  received  in 
vessels  of  water  containing  such  a  solution,  and  all  vessels  used  shall 
be  kept  scrupulously  clean  and  thoroughly  disinfected. 

"Discharges  from  the  throat,  nose,  and  mouth  shall  be  received 
upon  pieces  of  cloth,  which  must  be  immediately  burned. 

"All  persons  recovering  from  either  diphtheria  or  scarlet  fever 
shall  be  considered  dangerous,  and  shall  not  be  permitted  to  associate 
with  others,  or  to  attend  school,  church,  or  any  pixblic  assembly,  until 
a  certificate  has  been  furnished  by  the  health  officer  to  the  effect  that 
they  may  go  abroad  without  danger  of  disseminating  the  contagion. 

"It  shall  be  the  duty  of  the  person  in  charge  of  the  premises 
where  a  case  of  diphtheria  or  scarlet  fever  exists,  to  exercise  all  rea- 
sonable care  in  the  prevention  of  the  commingling  of  persons  who 


DIPHTHERIA  AND  SCARLET  FEVER.  561 

come  into  contact  with  the  patient,  or  any  other  persons,  whereby  the 
contagion  might  be  disseminated. 

"The  body  of  a  person  who  died  from  either  diphtheria  or 
scarlet  fever  shall  be  immediately  disinfected  and  placed  in  a  coffin, 
which  shall  be  tightly  closed,  and  shall  not  be  taken  to  any  church 
or  place  of  public  assembly,  and  shall  be  buried  within  forty-eight 
hours,  unless  otherwise  ordered  by  the  health  officer. 

"No  public  funeral  shall  be  held  in  a  dwelling  in  which  there  is 
a  case  of  either  diphtheria  or  scarlet  fever,  nor  in  which  a  death  from 
either  of  said  diseases  has  recently  occurred. 

"Immediately  upon  the  recovery  of  a  person  who  has  been  suf- 
fering from  either  diphtheria  or  scarlet  fever,  or  upon  the  death  of 
a  person  who  has  been  so  suffering,  the  room  or  rooms  occupied  shall 
be  thoroughly  disinfected  by  exposure  for  several  hours  to  the  fumes 
of  chlorine  gas,  or  of  burning  sulphur,  and  shall  thereafter  be  thor- 
oughly cleaned  and  exposed  to  currents  of  fresh  air. 

"All  clothing,  bedding,  carpets,  and  other  textiles  which  have 
been  exposed  to  the  contagion  of  the  disease  shall  be  either  burned, 
exposed  to  superheated  steam,  or  thoroughly  boiled. 

"No  person  shall  interfere  with  or  obstruct  the  entrance,  inspec- 
tion, and  examination  of  any  building  or  house,  by  the  inspectors  or 
officers  of  this  department,  when  there  has  been  reported  the  case  of 
a  person  sick  with  either  scarlet  fever  or  diphtheria  therein." 

Biagnosis  of  Diphtheria.- — For  the  more  prompt  and  certain 
diagnosis  of  diphtheria,  small  wooden  boxes  are  distributed  to  the 
various  pharmacies  in  Washington,  each  box  holding  two  glass  tubes, 
one  tube  containing  a  small  cotton  swab,  the  other  containing  solidi- 
fied blood-serum  as  a  culture  medium.  Each  tube  is  sterilized  and 
plugged  with  cotton.    The  following  notice  is  inclosed  in  each  box : — 

Directions  for  Making  Cultures  in  Suspected  Cases  of 
Diphtheria. 

"The  patient  should  be  placed  in  the  best  light  attainable,  and, 
if  a  child,  properly  held.  In  cases  where  it  is  possible  to  get  a  good 
view  of  the  throat,  depress  the  tongue  and  rub  the  cotton  swab  gently, 
but  freely,  against  any  visible  pseudomembrane  or  exudate.''^ 

"In  other  cases,  including  those  in  which  the  exudate  is  confined 
to  the  larynx,  open  tlie  mouth  and  pass  the  sM'ab  Ijack  till  it  reaches 


''This  fihoiild  be  dono  before  any  germicide  has  been  applied,  and,  if 
thin  has  hcen  done,  allow  at  h^ast  an  hour  to  intervene  l)efoie  making  the 
inofiilatiori. 


562  TEXT-BOOK  OF  HYGIENE. 

the  pharynx,  and  then  rub  it  freely  against  the  mucous  membrane. 
Without  laying  the  swab  down,  withdrew  the  cotton  plug  from  the 
culture-tube,  insert  the  swab,  and  rub  that  portion  of  it  which  has 
touched  the  exudate  gently  back  and  forth  along  the  surface  of  the 
blood-serum.  Then  replace  the  swab  in  its  own  tube,  plug  both  tubes, 
and  send  the  whole  outfit  at  once  to  the  laboratory. 

"A  report  will  be  forwarded  the  following  morning,  by  mail,  or 
can  be  obtained  by  telephone." 

TUBERCULOSIS. 

With  the  discovery  by  Koch  of  the  cause  of  tuberculosis,  and  the 
numerous  researches  made  by  him  and  other  observers  into  the  nature 
of  the  tuberculous  poison,  has  growTi  conviction,  of  late  years,  that 
tuberculosis,  being  communicable,  is  to  a  large  extent  preventable. 
The  hacillus  tttherciilosis.  is  the  etiological  factor  of  most  importance 
in  the  spread  of  tuberculosis ;  it  has  been  proved  that  it  is  contained 
in  large  numbers  in  the  sputum  of  tuberculous  patients,  and  that, 
unlike  most  microorganisms,  its  vitality  is  not  destroyed  by  drying. 
Therefore,  with  the  careful  disinfection  or  destruction  of  the  ex- 
pectoration of  tuberculous  patients,  one  most  important  factor  in  the 
dissemination  of  tuberculosis  will  be  removed.  In  almost  all  large 
hospitals,  at  the  present  day,  the  practice  obtains  of  either  isolating 
the  tuberculous  patients  or  of  segregating  them  in  special  wards  or 
apartments.  With  a  view  of  preventing  the  spread  of  tuberculosis, 
the  Board  of  Health  of  New  York  City  has  issued  in  English,  Ger- 
man, Hebrew,  and  Italian  the  following  circular  for  popular  instruc- 
tion : — 

"Consumption  is  a  disease  which  can  be  taken  from  others,  and 
is  not  simply  caused  by  colds.  A  cold  may  make  it  easier  to  take  the 
disease.  It  is  usually  caused  by  germs  which  enter  the  body  with  the 
air  breathed.  The  matter  which  consumptives  cough  or  spit  up  con- 
tains these  germs  in  great  numbers;  frequently  millions  are  dis- 
charged in  a  single  day.  This  matter,  sj)it  upon  the  floor,  wall,  or 
elsewhere,  is  aj)t  to  dry,  become  pulverized,  and  float  in  the  air  as 
dust.  This  dust  contains  the  germs,  and  thus  they  enter  the  body 
with  the  air  breathed.  The  breath  of  a  consumptive  does  not  contain 
the  germs,  and  will  not  produce  the  disease.  A  well  person  catches 
the  disease  from  a  consumptive  only  by  in  some  way  taking  the  matter 
coughed  up  by  the  consumptive. 

"Consumption  can  often  be  cured  if  its  nature  is  recognized  early 


TUBERCULOSIS.  563 

and  proper  means  are  taken  for  its  treatment.  In  a  majority  of  cases 
it  is  not  a  fatal  disease. 

"It  is  not  dangerous  for  other  persons  to  live  with  a  consumptive 
if  the  matter  coughed  up  by  the  consumptive  is  at  once  destroyed. 
This  matter  should  not  be  spit  upon  tlie  floor,  carpet,  stove,  wall,  or 
street,  or  anywhere  except  into  a  cup  kept  for  that  purpose.  The  cup 
should  contain  water,  so  that  the  matter  may  not  dry,  and  should 
be  emptied  into  the  closet  at  least  twice  a  day,  and  carefully  washed 
with  hot  water.  Great  care  should  be  taken  by  a  consumptive  that 
his  hands,  face,  and  clothing  do  not  become  soiled  with  the  matter 
coughed  up.  If  they  do  become  soiled,  they  should  be  at  once  washed 
with  hot  water  and  soap.  When  consumptives  are  away  from  home, 
the  matter  coughed  up  may  be  received  on  cloths,  which  should  be  at 
once  burned  on  returning  home.  If  handkerchiefs  are  used  (worth- 
less cloths  which  can  be  burned  are  far  better) ,  they  should  be  boiled 
in  water  by  themselves  before  being  washed. 

"It  is  better  for  a  consumptive  to  sleep  alone,  and  his  bed-cloth- 
ing and  personal  clothing  should  be  boiled  and  washed  separately 
from  the  clothing  belonging  to  other  people. 

"Whenever  a  person  is  thought  to  be  suffering  from  consumption, 
the  name  and  address  should  be  sent  at  once  to  the  health  depart- 
ment, on  a  postal  card,  with  a  statement  of  this  fact.  A  medical  in- 
spector from  the  health  department  will  then  call  and  examine  the 
person  to  see  if  he  has  consumption,  providing  he  has  no  physician, 
and,  if  necessary,  will  give  proper  direction  to  prevent  others  from 
catching  the  disease. 

"Frequently  a  person  suffering  from  consumption  may  not  only 
do  his  usual  work  without  giving  the  disease  to  others,  but  may  also 
get  well,  if  the  matter  coughed  up  is  properly  destroyed. 

"Eooms  that  have  been  occupied  by  consumptives  should  be  thor- 
oughly cleaned,  scrubbed,  whitewashed,  painted  or  papered  before  they 
are  again  occupied.  Carpets,  rugs,  bedding,  etc.,  from  rooms  which 
have  been  occupied  by  consumuptives,  should  be  disinfected.  The 
health  department  should  be  notified,  when  they  will  be  sent  for,  dis- 
infecterl,  and  returned  to  the  owner  free  of  charge;  or,  if  he  so  desire, 
they  will  be  destroyed." 

In  view  of  the  possibility  that  patients  convalescing  from  diph- 
theria may  harbor  the  bacilli  for  some  time  after  disappearance  of 
clinical  symptoms,  it  is  advisable  to  maintain  quarantine  until  two 
successive  cultures  show  the  absence  of  diphtheria  bacilli  from  the 
thi'oat. 


564  TEXT-BOOK  OF  HYGIENE. 

THE  SANATORIUM   TREATMENT  OF  TUBERCULOSIS. 

i\.s  a  restrictive  measure  against  the  spread  of  tuberculosis,  the 
sanatorium  treatment  of  the  disease  affords  results  which  are  hardly 
less  gratifying  than  the  curative  effects  of  such  treatment.  This  will 
be  readily  appreciated  when  it  is  remembered  that  every  consumptive 
in  his  home  is  a  possible  and  potential  focus  for  the  dissemination 
of  the  infection,  and  that  when  he  is  removed  to  a  sanatorium  there 
is  one  less  center  of  infection  to  be  dealt  with.  It  has  been  demon- 
strated that  under  judicious  and  scientific  administration  the  con- 
sumptive sanatorium  does  not  become  itself  infected,  and  that  the 
patients  under  the  influence  of  a  liberal  dietary,  life  practically  in 
the  open  air,  regulated  exercise  and  regular  habits  of  life,  improve 
or  become  actually  cured  in  a  percentage  of  cases  which  is  very  grati- 
fying, and  affords  strong  grounds  for  hope  in  the  gradual  abolition 
of  pulmonary  tuberculosis. 

The  results  attained  in  the  treatment  of  tuberculosis  at  the  Fort 
Stanton  Sanatorium,  Fort  Stanton,  X.  M.,  are  thus  summarized  by 
Surgeon  P.  M.  Carrington,  who  is  in  command  of  the  station : — 

"1.  Given  a  sufficient  length  of  stay  recovery  may  be  e?cpected 
in  a  very  large  percentage  in  first  stage  uncomplicated  cases. 

"2.  Eecovery  or  arrest  may  be  expected  in  a  fair  proportion  of 
second  and  third  stage  cases  and  all  the  afebrile  cases  in  which  there 
remains  sufficient  sound  lung  tissue  to  support  life,  but  we  should 
exercise  caution  lest  we  be  premature  in  pronouncing  second  and  third 
stage  cases  cured. 

"3.  Eesults  in  permanent  febri'e  cases,  especially  those  in  which 
there  is  a  wide  range  of  daily  temperature,  are  not  better  than  in  less 
favorable  climates. 

"4.  Hemorrhages  seem  less  liable  at  this  altitude  than  at  the 
sea-level. 

"5.  Heredity  plays  an  unimportant  part  in  the  causation  of  the 
disease." 


QUESTIONS  TO  CHAPTER  XX. 

QUARANTINE. 

What  is  meant  by  quarantine?  From  what  is  the  term  derived?  Has 
it  now  any  definite  limitation  as  to  time?  To  what  is  the  term  applied? 
What  are  the  two  natural  divisions  of  quarantine?  What  are  the  principal 
quarantinable  diseases?  What  determines  the  length  of  quarantine  for  each 
of  these?    Should  tuberculosis  be  quarantinable? 

What  is  meant  by  foreign  quarantine?  What  regulations  are  now  to  be 
observed  at  foreign  ports  by  vessels  clearing  for  the  United  States?  What 
oflncers  have  charge  of  this  foreign  quarantine  ? 

What  are  some  of  the  points  considered  in  the  bill  of  health?  What  are 
some  of  the  requirements  with  regard  to  vessels  and  their  cargoes?  Regard- 
ing passengers  and  crew?  What  are  the  objects  of  the  inspection  card  given 
to  passengers? 

What  requirements  are  to  be  observed  at  sea?  What  method  is  pre- 
scribed for  the  disinfection  of  vessels?  Of  cargoes?  What  can  be  said  of  the 
efficiency  of  the  foregoing  regulations? 

What  is  meant  by  domestic  quarantine?  What  will  govern  the  equip- 
ment of  a  maritime  quarantine  station?  What  are  required  at  a  fully- 
equipped  station?  What  is  the  method  of  construction  of  the  most  recent 
steam  disinfecting  chambers,  and  in  what  ways  are  they  superior  to  the 
earlier  models?  What  precautions  are  to  be  observed  in  operating  them? 
What  is  the  principle  of  construction  of  the  sulhpur-furnaces  now  used  at 
quarantine  stations,  and  wherein  are  they  superior  to  other  methods  of 
producing  sulphurous-acid?  How  is  ths  gas  to  be  conveyed  into  the  holds  of 
vessels,  etc.?  What  apparatus  is  provided  for  using  germicidal  solutions 
Where  barracks  are  necessary,  how  should  they  be  arranged  and  equipped? 
What  facilities  for  bathing  should  be  provided?  What  is  to  be  said  of  the 
water-supply  ? 

What  regulations  are  to  be  observed  at  ports  of  entry  and  on  the  fron- 
tier? What  points  are  covered  by  the  inspection,  and  what  vessels  are  exempt 
from  inspection?  What  vessels  are  to  be  quarantined,  and  for  how  long? 
What  are  the  general  requirements  at  quarantine?  What  treatment  must 
cholera-infected  vessels  undergo  in  quarantine?  What  is  the  prescribed  method 
of  disinfection  ?  What  routine  is  to  be  observed  with  passengers  detained  on 
account  of  cholera? 

Under  what  conditions  may  traffic  be  allowed  from  ports  infected  with 
yellow  fever?  What  inspection  is  required  of  State  and  local  quarantines? 
What  regulations  govern  the  Canadian  and  Mexican  frontiers?  What  are 
some  of  the  points  to  be  observed  in  the  successful  management  of  a  quar- 
jintine  station? 

(565) 


666  TEXT-BOOK  OF  HYGIENE. 

What  is  the  treatment  required  for  cholera-infected  vessels?  What 
special  measures  are  to  be  taken  against  cholera?  Who  has  supreme  com- 
mand of  a  cholera  camp,  and  how  is  it  to  be  divided?  What  are  the  regu- 
lations to  be  observed  in  the  detention  camp?  In  the  hospital  camp?  Why 
should  infected  dejecta  and  ejecta  be  disinfected  immediately  upon  discharge? 

How  many  national  quarantine  stations  are  there,  and  where  are  they 
located?  Give  a  brief  description  of  those  in  the  Delaware  Bay  and  River. 
What  government  vessel  is  used  as  a  quarantine  station? 

What  are  some  of  the  aids  to  national  quarantine?  Wliat  inspection 
is  required  of  all  quarantines?  What  is  required  of  all  State  and  local  quar- 
antines? What  are  the  instructions,  both  general  and  special,  to  the  officers 
detailed  to  inspect   State  and  local  quarantines? 

What  is  meant  by  inland  quarantine?  By  the  sanitary  cordon?  When 
and  where  has  the  latter  been  employed  in  the  United  States,  and  with  what 
success?  What  is  a  camp  of  probation?  What  is  the  difference  between  it 
and  a  camp  of  refuge?  How  should  a  camp  of  probation  be  equipped,  man- 
aged, and  guarded?  What  should  be  the  daily  roiitine  of  such  a  camp?  What 
regulations  should  be  promulgated  and  enforced  for  such  a  camp?  Have 
these  camps  been  efficacious  ih  preventing  the  spread  of  disease  ? 

What  is  the  purpose  of  railroad  quarantine,  and  how  is  it  to  be  carried 
out?  How  may  it  be  facilitated  by  train-inspection  service?  What  rules  are 
to  be  adopted  for  railway  quarantine?  What  action  has  been  taken  to  pre- 
vent the  introduction  of  small-pox,  etc.,  from  Canada?  Wliat  are  the  regula- 
tions issued  for  the  guidance  of  sanitary  inspectors?  What  provisions  are 
there  for  the  medical  inspection  of  immigrants  on  board  trains? 

What  general  principles  govern  interstate  quarantine?  What  are  the 
regulations  covering  it?  Which  of  these  is  the  most  important?  What  spe- 
cial provisions  are  made  respecting  yellow  fever  ?  What  are  the  methods  of 
disinfection  prescribed,  respectively,  for  cholera,  yellow  fever,  small-pos,  and 
typhus  fever? 

Wliat  are  the  essential  points  of  municipal  quarantine?  What  precau- 
tions are  to  be  taken  to  prevent  the  spread  of  small-pox,  measles,  diphtheria, 
ai.d  scarlet  fever?  To  what  extent  should  domiciliary  quarantine  be  carried? 
How  long  should  it  be  maintained? 

How  may  a  diagnosis  of  diphtheria  be  made?  What  means  may  be 
taken  to  prevent  the  spread  of  tuberculosis? 

Give  a  synopsis  of  the  quarantine  laws  of  the  United  States.  What  is 
the  maximum  penalty  for  attempting  to  enter  a  port  in  evasion  of  them? 
What  information  of  value  to  quarantine  officers,  etc.,  is  furnished  weekly? 
When  and  by  whom  may  travel  and  traffic  from  infected  ports  and  places  be 
prohibited?  Who  has  supreme  charge  of  the  enforcement  of  the  quarantine 
regulations?  In  what  aepartment  of  the  government  does  the  supervision  of 
quarantine  belong? 


INDEX. 


Abscesses,    resume   of,   437. 
Acclimatization     to     diminished    air-pres- 
sure, 9. 
Actinomycosis,    434. 

resume  of,   438. 
Acute  Infectious  diseases,  propagation  of, 

7,  16. 
Adulteration  of  foods,  147,  148. 
Air,  1.     See  also  Atmosphere, 
absorption    of    heat   and    aqueous    vapor 

by,  4. 
ammonia  in,   27. 
bacteria  in,  6. 
bacteriological    examination   of,    31. 

quantitative,    33. 
carbon    dioxide    in,    limit    of,    allowable, 

38. 
carburetted  hydrogen  in,  27. 
-currents,   sanitary  relations  of,   16. 
determination  of  organic  matter  in,  33. 
dry,  in  the  causation  of  respiratory  dis- 
eases, 14. 
dust  in,   28. 
carrying  bacteria,  28. 
in  cities,  28. 
examination  of,  29. 
for  ammonia,  37. 
for  bacteria,    31. 

for  carbon    dioxide,    author's    method, 
34. 
Boom's  method,   33. 
Pettenkofer's  method,  35. 
for  carbon  monoxide,  37. 
for  gases,  37. 
for  organic  matter,  33. 
for  ozone,  30. 

Houzeau's  test  for,  30. 
for  solid  impurities,  30. 

Dixon's  method,  30. 
for  sulphur,  37. 

substances  to  determine  in,  29. 
exhausting,    from    old    wells    and   privy- 
vaults,  28. 
ground-,  161. 

impurities  in  respired,  where  found,   41. 
infection  by  contaminated,   7. 
-passages,    diseases    of,    caused    by    low 

temperature,  13. 
-pressure,  acclimatization  to  diminished. 
9. 
effect  of  diminished,  8. 
purity  of,  in  wells  and  privy-vaults,  test 
for,  29. 


Air,  questions  to  Chapter  I  on,  43. 
sanitary    relations    of    changes    in    com- 
position   and    impurities    of, 
23. 
source  of,  for  ventilation,  39. 
-space,  dimensions  of,  per  person,  39. 
initial,  39. 

Morin's  table   showing   proper  propor- 
tion of,   40. 
sulphuretted  hydrogen  in,  27. 
-tester,  34. 
warmth  of,  4. 

wind   caused   by   dififereuces  in   pressure 
of,  6. 
Ale,  143. 

Alcohol,   abstainers  and  users  of,  table  of 
expectation  of  life  of,  141. 
amount  of,  in  various  medicines,  144. 
as  a  beverage,  143. 
ale,  143. 
beer,  143. 
brandy,  142. 
brown-stout,  143. 
forms  of,  142. 
gin,  142. 
kumys,  143. 
porter,  143. 
whisky,  142. 
wine,  142. 
adulteration  of  foreign,  142. 
beverages  containing,  138. 
"deadly  parallel"  between  food  and,  139. 
fatality  of  croupous  pneumonia  in  users 

of,  141. 
influence    of,    upon    the    mortality    from 
nervous        diseases,        table 
showing,    141. 
pathological  effect  of,  140. 
physiological  effect  of,  138. 
predisposition     to     disease    in    habitual 

users  of,  141. 
therapeutic  effect  of,  138. 
Alimentary  •  overages,   138. 
Alkaloidal     beverages.       See     Beverages, 

Alkaloidal. 
Altitude,  atmospheric  pressure  in  relation 
to,    table   showing,    3. 
high,   effects  of,   8. 
Alum,  examination  for,  in  bread,  155. 
Ammonia,    albuminoid,    in    water,    deter- 
mination of,  101. 
free,  in  water,  determination  of,  101. 


(567) 


568 


INDEX. 


Ammonia  in  air,  27. 

determination  of,   37. 
in   sewer-air,    27. 
in  water,  source  of,  82. 
poisoning  by,  250. 
Anchorages,  489. 

Aniline  vapor,  poisoning  by,  257. 
Animals,  diseases  of,  due  to  conditions  of 

the  soil,  169. 
Annatto,  test  for,  152. 
Anthrax,  435. 

resume  of,  438. 
Antiseptics,  disinfectants,  and  deodorants, 
447. 
antiseptics,   table  of,  459. 
definitions  of,  447,  448. 
deodorizers,  460. 

disinfectants  for  clothing,  bedding,  etc., 
450. 
for  excreta,  450. 
for  furniture,  etc.,  451. 
■     for  merchandise  and  the  mails,  451. 
for  non-spore-containing  matter,  449. 
for  rags,  451. 
for  railway  cars,   452. 
for  ships,   452. 

for  spore-containing  matter,  449. 
for  the  dead,  451. 
for  the  person,  451. 
for  the    sick-room  and  hospital  wards, 

451. 
formaldehyde,  456. 
and  potassium  permanganate,  457. 
danger  of,  458. 
two  classes  of,  449. 
disinfection  of  clothing,  453. 
of  excreta,  452. 
of  ingesta,  455. 

of  privy-vaults,  cess-pools,  etc.,  455. 
of  the  person,  453. 
cf  the  sick-room,  454. 
questions  on,  461. 
resistance  of  certain  bacteria  to,  table  of, 

448. 
table  of  antiseptics,  459. 
Artesian   wells,   61. 
Artificial   sea-bath,   recipe   for  ingredients 

of,  859. 
Asiatic   cholera,   history  of,   409. 
Atmosphere,     certain     diseases     communi- 
cable by,  7.     See  also  Air. 
composition   and  physical   conditions   of, 

2. 
effect  of  rarefied,   on  phthisis,  10. 
electrical  and  magnetic  conditions  of,  6. 
humidity  of,   connected  with  changes  in 

health,  16. 
infection     of,     by     coughing,     sneezing, 

speaking,  and  exhaling,  7. 
influence     of     electrical     conditions     of, 
upon  health,  17. 


Atmosphere,    varieties   of  pathogenic   bac- 
teria found  in,  28. 
Atmospheric  pressure,    3. 
causes  of  variations  in,   3,   4. 
increased,  11. 

effects  of,   11. 
influence  of  changes  of,  on  health,  7. 
relation  of  humidity  to,   4. 
relation  of,  to  altitude,  table  showing,  3. 

Bacilli,  typhoid,  in  ice,  54. 

Bacillus  coli,  effect  of  solutions  of  metals 

upon,  81. 
Bacteria  in  air,  6. 

examination   for,  31. 
harmless,  7. 
pathogenic,   7. 
putrefactive,   7. 
role  of  dust  in  carrying,  7. 
in    drinking-water.      See    Water,    Drink- 
ing-, 
in  sewer-air,   27. 

of  non-putrefactive  decomposition,  166. 
table   showing  resistance    of   certain,    to 

disinfectants,  448. 
varieties  of  pathogenic,  found  in  air,  28. 
Bactericidal  action  of  metals,  81. 
Bacteriological  examination  of  water,   105. 
Bacterium  of  non-putrefactive  decomposi- 
tion, 166. 
of  putrefaction,  366. 
Baker,   H.   B.,   observations  on  relation  of 
respiratory   diseases   to    low 
temperature,  13. 
Baking,    broiling   and,    137. 
Barometric  pressure,  effect  of,  10. 
Barracks,   493. 
Bath-house,   493. 

Baths  and  bathing.    See  Personal  Hygiene. 
Battlefield,  interment  on,  372. 
Beans,   134,   135. 
Beer,  143. 

Beverages,  alimentary,  138. 
alkaloidal,  145. 
chocolate,  146. 

nutritive  properties  of,   146. 
coffee,  145. 
adulteration  of,  146. 
artificial,   145. 
tea,   146. 
adulteration  of,  146. 
containing   alcohol,    138.     See  also   Alco- 
hol. 
Bilge-water.     See  Marine  Hygiene. 
Birth-rate  and  death-rate,  466. 
Births,  registration  of,  464. 
Bisulphide  of  carbon,   poisoning  by,  253. 
Boarding-station,    489. 

-vessel,  489. 
Boiling,  136. 
Bovine  tuberculosis,  435. 


INDEX. 


569 


Brandy,  142. 

Bread.     See  Foods  of  Vegetable  Origin. 

Broiling  and  baking,  137. 

Bromine  and  iodine  vapors,  poisoning  by, 

254. 
Brown-stout,  143. 
Building-site,  194. 

Burial  grounds,   supposed  dangers  of,  370. 
Butter.     See  Foods  of  Animal  Origin. 

Caisson   disease,   11. 

prevention  of,  11. 
Calorie,  113. 

definition  of,  113. 
Camp  diseases,  279. 
hygiene,  military  and.     See  Military  and 
Camp   Hygiene. 
Camps,  sanitary  care  of,  277. 
Candles,  203. 

Carbon  bisulphide,  poisoning  by,  253. 
dioxide,   determination  of,  33. 
effects  of,  24,  25. 
excess  of,   in  water,   effect  of,   on  lead 

pipes,  78. 
in  water,  dangerous  proportion  of,  78. 
poisoning  by,  252. 

proportion  of,   in  the  atmosphere,  38. 
allowable,  23,  24. 
monoxide,   26. 
poisoning  by,  251. 
test  for,  37. 
Carburetted  hydrogen,  "fire-damp,"  in  the 
air,  27. 
poisoning  by,   252. 
Carriers   of   infection,    387. 
Casualties    and    disabilities    due    to    ship- 
wreck, 296. 
Cerebro-spinal   meningitis,    epidemic,    his- 
tory of,  429. 
Cess-pools    as    sources    of    contamination, 
50. 
disinfection  of,  455. 
Cider,  143. 

Chalk  strata  in  relation  to  hygiene,  196. 
Chart,   acute  lung  diseases,  19. 
consumption,  18. 

cause  of  death  of  seafaring  people,   292. 
diarrheal  diseases,  20. 
diphtheria  and  croup,  22. 
diseases  of  seafaring  people,  293. 
typhoid  fever,  21. 
Cheese.     See  Foods  of  Animal  Origin. 
Chimney  as  a  ventilator,  41. 
Chlorine-gas,  poisoning  by,  251. 
Chocolate,   146. 
Choke-damp,  29,  252. 

poisoning  by,  252. 
Cholera,  Asiatic,  history  of,  409. 
epidemic  of,  at  Hamburg,   85. 
in   soldiers,  283. 
resum6  of,  438. 


Cholera,    special    measures    against.      See 
Quarantine. 

spirillum  in   water,  77. 

transmitted  by   drinking-water,   76. 

vessels.     See  Quarantine. 
Cisterns,  above  ground,  50. 

underground,   50. 
contamination   of,   50. 
Clay,  dense  marls,  and  alluvial  soils,  197. 

slate,   the,   196. 
Climate  and  diarrheal  diseases,  12. 
Clothing.     See   Personal  Hygiene. 

disinfection  of,   453. 
Coal-gas,  composition  of,  26. 
Coca,   146. 
Coffee,   145. 

ground,   adulteration  of,   146. 
Cold,  respiratory  diseases  caused  by,  13. 
Color  of  water,   100. 

significance  of,  100. 
Construction  of  habitations,  192. 

of  hospitals,   219. 
Contagion  and  infection,  385. 

carriers  of  infection,  387. 

differentation  of,  385. 

incubation  period  of  infectious  diseases, 
table  of,  386. 

period  of  infectiousness  of  patient,  387. 

questions  on,  390. 
Cooking,   136. 

Copper  and  other  metals,   bactericidal  ef- 
fect of,    81. 
Creamometer,   123,   124. 
Cremation.      See    Dead,    Disposal    of. 
Crematory,   494. 
Cultivated    soils,    197. 
Cysticercus  cellulosa  in   meat,   129. 

Danger  from  lead  pipe  as  a  conductor  of 

water,  78. 
Dead,    disposal   of,    369. 
cremation,    371. 
entombment  in  vaults,  371. 
interment,    369. 

on   the  battlefield,    372. 
methods  of,   369. 
questions  on,  373. 

supposed    dangers    of    burial    grounds, 
370. 
Death-rate    among   persons    living   in    dif- 
ferent stories  of  houses,  193. 
among    young    children    as    a    result    of 

overcrowding,  194. 
and    birth-rate,    466. 

relation    of,    to    density    of    population, 
table  on,  192. 
Deaths,    registration   of,   466. 
Decomposition,      non-putrefactive,      bacte- 
rium of,   166. 
Dengue,   history   of,    427. 
Deodorants,    447. 


570 


INDEX. 


Deodorization   of   contents   of   privies,   173. 
Deodorizers,   460. 
Dermatitis  from  sun's  cays,  12. 
Diarrhea  in  soldiers,  279. 
Diarrheal  diseases  in  the  summer,  12. 
Diminished  air-pressure,   effect  of,  8. 
Diphtheria,  diagnosis  of,  561. 
directions    for   making    cultures   in   sus- 
pected cases  of,  561. 
history  of,  426. 
quarantine  of,  559. 
resume  of    438. 
Disease,  diminution  of,  due  to  drainage  of 
wet   soil,   194. 
germ  theory  of,  374. 
questions   on,    384. 
mosquito    transmission    of,    management 
of  epidemics  of  yellow  fever 
in    the   light   of,    542. 
Diseases,  acute  infectious,  propagation  of, 
7,  16. 
camp,    279. 

contagious  and  infectious,  Vacher's  table 
of   the  time-periods   of,   241. 
Whitelegge's  table  showing  periods  of 
quarantine  after,  242. 
due  to  absorption  or  local  action  of  irri- 
tating    or     poisonous     sub- 
stances,   261. 
constrained  attitude  and  sedentary  life, 

265. 
excessive  use  of  certain    organs,  263. 
exposure  to  elevated  or  variable  tem- 
perature      or      atmospheric 
pressure,    263. 
exposure  to  mechanical  violence,  265. 
impure  drinking-water,  64. 
inhalation    of    irritating    or    poisonous 
dust,  258. 
gases  or  vapors,   250. 
epidemic,  history  of,  391. 

cerebro-spinal    meningitis,    epidemic, 

429. 
cholera,   Asiatic,   409. 
dengue,  427. 
diphtheria,  426. 
gonorrhea,  433. 
influenza,  epidemic,  428. 
measles,  425. 
meningitis,   cerebro-spinal,   epidemic, 

429. 
questions  on,  442. 
relapsing  fever,  419. 
scarlet  fever,  425. 
small-pox,   396. 
inoculation,  399. 
vaccination,  401. 
Jcnner,  Edward,  402. 
sweating  sickness,  395. 
syphilis,   430. 
typhoid  fever,  420. 


Diseases,   epidemic,  typhus  fever,  421. 
yellow    fever,    423. 
in  hot  climates,  12. 
in  infants,  26. 
incident  to  school  life,   235. 
infectious,  resume  of  some  of  the,  437. 
abscesses,  437. 
actinomycosis,  438. 
anthrax,    438. 
cholera,  438. 
diphtheria,   438. 
dysentery,  438. 
glanders,  438. 
gonorrhea,   439. 
hydrophobia,  439. 
influenza,    439. 
leprosy,   439. 
malaria,   439. 
measles,  439. 
mumps,  439. 
parotitis,  439. 
pertussis,   441. 
plague,  439. 
pneumonia,  439.        — 
rabies,   439. 
relapsing  fever,  440. 
scarlet  fever,  440. 
small-pox,  440. 
syphilis,    440. 
tetanus,   440. 
typhoid   fever,   440. 
typhus,  440. 
tuberculosis,   440. 
whooping-cough,   441. 
yellow  fever,   441. 
most  frequent  in  prisons,  350. 
of  animals  communicable  to  man,  434. 
actinomycosis,  434. 
anthrax,   435. 
bovine  tuberculosis,  435. 
glanders,  437. 
questions  on,   446. 
rabies,  435. 
sheep-pock,   434. 
tuberculosis,   bovine,  435. 
probably  due  to  similar  conditions  of  the 

soil,  169. 
quarantinable,  473. 

table  of,  473. 
registration  of,    465. 
spread  by  soil  impurities,  116. 
Disinfectants.      See    Antiseptics,    Disinfec- 
tants, and  Deodorants. 
Disinfecting  chambers,   steam,   490. 

sulphur-furnace,  491. 
Disinfection   by   germicidal    solutions,   492. 

of  ships.      See   Marine  Hygiene. 
Disposal   of   the   dead.      See  Dead. 
Dixon's  aeroscope,    30. 
Drains,   best  material  for,  170. 
depth   for,   170. 


INDEX. 


571 


Drains,  trees  for,  170,  198. 
Drainage,    170. 
of  ships.     See  Marine  Hygiene, 
-pipe,  170. 
Drinking-water,     62.       See     also     Water, 
Drinliing-. 
contamination   of,   by   excrement,    50. 
from    ice   and    snow,    62. 
limit  of  solid  matter  allowable   in,   63. 
sources  of,   50. 
Dust,   diseases   due    to    inhalation   of   irri- 
tating   or   poisonous,    258. 
coal-dust,  258. 
metallic  dust,  258. 
mineral  dust,  258. 
vegetable  dust,  259. 
in  air,  28. 

carrying  bacteria,  28. 
nature  of,   31. 

occupations  concerned  in  making,  249. 
Dwellings.    See  Habitations. 
Dysentery  in  soldiers,  279. 
resume  of,  438. 

Earth-closet,  177. 

Effluvia  from  cemeteries  and   knackeries, 
27. 

Eggs.     See  Foods  of  Animal  Origin, 
from  persons   and  discharges  of  sick  in 
air,  38. 

Electric  light,   204. 

Electrical  and  magnetic  conditions  of  the 
atmosphere,  6. 

Epidemic    cerebro-spinal    meningitis,    his- 
tory of,  429. 
diseases  in  hot  climates,  12. 
influenza,  history  of,   428. 

Epidemics,    typhoid,    due   to   contaminated 
water-supply,  66-76. 

Erythema  from  sun's  rays,  12. 

Eucalyptus  tree  for  draining  soil,  170,  198. 

Examination,     bacteriological,     of     water. 
See  Water, 
of  food,  150. 
of  water,  93. 

Excrement  contaminating  drinking-water, 
50. 

Excreta,  disinfection  of,  152. 

Exercise  and  training.     See  Personal  Hy- 
giene. 

Fat  in  milk.     See  Foods  of  Animal  Origin. 
Fever,  relapsing.     See  Relapsing  Fever. 

scarlet.      See    Scarlet   Fever. 

typhoid.     See  Typhoid  Fever. 

typhus.    See  Typhus  Fever. 

yellow.     See  Yellow  Fever. 
Filters,    comparative   utility   of  slow   sand 
and  mechanical,  92. 

domeHtif,   81. 

mechanical,  90. 


Filters,   mechanical,   chemicals  used  with, 
91. 
cleansing   of,    91. 
efficiency  of,  92. 
principles  of,  90. 
slow   sand,    construction   of,   84,  85. 
first  in  America,   88. 
Filtration,    81. 
conclusions  of  R.  Koch  upon,  86. 
Dr.   A.   Robin's  conclusion  from  experi- 
ments at  Wilmington,   Del., 
87-88. 
slow  sand,  84. 
effect  of,  84. 

general  installation  of,  88,  90. 
principles  of,  84. 
summary  of  experiments  upon,  87. 
table    of    comparative    mortality    before 
and  after,  88,  89. 
Fire-damp,  252. 
dangers  of,  252. 
in    mines,    27. 
Flies,   danger  from,    in  quarantine,   526. 
Food,  110. 
adulteration  of,  147,  148. 
adulterations  of,  table  showing  detection 
of,    in   one  year   in   Illinois, 
149. 
albuminoid  proximate  principles  of,  117. 
caloric  value  of,  to  calculate,  115. 
calorie,  113. 
carbohydrates,  118. 
definition  of,  110. 

dietaries,  standard,  Hutchison's,  114-115. 
dietary,     for     adult     male     of     average 
weight,  table  of.  111. 
standards   of,    111. 
examination  of,  150. 
butter,  152. 
oleomargarine,  153. 
insoluble  fatty  acids,  154. 
melting-point,  154. 
specific  gravity,  153. 
flour  and  bread,  154. 
for  alum,  155. 
for  copper  sulphate,  155. 
for  ergot,  155. 
for  gluten  in,  154. 
for  mineral  substances,  155. 
for  water  and  ash,  154. 
milk,   150. 
for  annatto,   152. 
for  boric  acid,  152. 
for  cane-sugar,  152. 
for  formaldehyde,  152. 
for  percentage  of  ash,  151. 
for  percentage  of  fats,  151. 
for  sodium  carbonate,  152. 
for  total  solids,  151. 
fat,  118. 
Increased  combustion  of,  118,  119. 


572 


INDEX. 


Food,    greater    consumption    of    carbohy- 
drates  during   exercise,    118. 
in  prisons,  350. 

materials    of    average    prices,    table    of 
comparative  cost  of  digesti- 
ble  nutrients  and  energy  in 
different,    112. 
nutrition,  physiology  of.  111. 
nutritive  ingredients  of,  table  of,  116. 
principles,   alimentary,   110. 

proximate,    110. 
proximate  principles  of,   110. 
quantity  and  character  of,  necessary,  110. 
fats  or  carbohydrates.  111. 
proteids.  111. 
salts,  110. 
water,  110. 
quantity    of    any    single    one    necessary 

for  existence,   117. 
questions  to  Chapter  III  on,  156. 
ration,  an  ideal,  115. 
reduced,  of  Chittenden,  115. 
of  Chittenden,  experiments  with,  116. 
relation  of  climate  to,  117. 
relative    proportion     of,     for     men     and 
women,  11.3. 
of    nitrogenous    to    non-nitrogenous, 
principles,  113. 
standard   dietaries,    Hutchison's,    114-115. 
unit  of   measurement  of   the   fuel-value 

of,    113. 
uses  of  nutrients  in  body,  117. 
water    and    other    inorganic    proximate 
principles  of,  118. 
Foods,    classification   of,   119. 
of  animal  origin,  119. 

adulteration  of,  147,  148. 
butter,   120,   125. 
cheese,   125. 
relative  value  of   different,   in  ali- 
mentary   principles,    126. 
eggs,  133. 

cooked,    digestibility  of,   133. 
fish,    oysters,    crabs,    and    lobsters, 
poisoning  by,  130. 
poisoning  by,  siguatera,  130. 
meat,   126. 
changes  in,   after  death.   127. 
parasites  in,  128. 
ptomaines  in,   129. 
putrefaction   of,    129. 
soluble  preparations  of,  127,  128. 
table  of  relative  proportions  of  fat 

and  proteids  in,  127. 
tainted,       prevention      of      disease 

from,  132. 
tuberculous,    131. 
unfit,   128,   129,   131,    132. 
prevention  of  disease  from,  132. 
ptomaines  in,  129. 
milk,  119. 


Foods,    of   animal    origin,    milk,    adultera- 
tion of,  121. 
determination  of  the  quality  of,  123. 
infection  by,  121,  122,  123. 
skim-milk,  121. 
specific  gravity  of,  124. 
tyrotoxicon  in,  124. 
whey,   120. 
oleo-margarine,   125. 
"swill-milk,"    123. 
of  vegetable  origin,  133. 

adulteration  of,   147,   148. 
bread,  133. 

substitutes  for,  134. 
condiments,  136. 
flour,  adulteration  of,  134. 
fruits  and  nuts,  135. 
green  vegetables,  135. 
leguminous  seeds,  134. 

composition  of,  135. 
rye,    disease   due  to,   134. 
Foodstuffs,  caloric  value  of,  115. 
Formaldehyde  as  a  disinfectant,   456. 
with  potassium  permanganate,  457. 
danger  of,  458. 
Frost-bite,  13. 
Frying,  137. 
Fungi,  lower,  in  air,  6. 

Gases  from  putrefaction,  poisoning  by,  253. 
or   vapors,   irritating  or   poisonous,    dis- 
eases  due    to   inhalation   of, 
250. 

ammonia,   250. 

aniline  vapor,  257. 

bisulphide  of  carbon,  253. 

bromine  vapor,  254. 

carbon  bisulphide,  253. 
dioxide,   252. 
monoxide,   251. 

carburetted  hydrogen,  252. 

choke-damp,  252. 

chlorine  gas,   251. 

copper  vapors,  256. 

fire-damp,   252. 

gases  from  putrefaction,  253. 

hydrochloric-acid  gas,  250. 

hydrogen,  carburetted,  252. 
sulphuretted,  253. 

iodine  and  bromine  vapors,  254. 

lead  poisoning,  254. 

mercurial  poisoning,  255. 

methane,    252. 

nitric-acid  fumes,  250. 

petroleum  vapor,  254. 

sulphuretted  hydrogen,  253. 

sulphurous-acid  gas,  250. 

turpentine  vapor,  254. 

zinc  or  copper  vapors,  256. 
Gas-light,  204. 
Germicidal   solutions,  disinfection  by,   492. 


INDEX. 


573 


Gin,  142. 
Glanders,  437. 

resume  of,   438. 
Gonorrhea,  history  of,  433. 

resume  of,  439. 
Granitic,    metamorphic,    and    trap    rocks, 

the,   195. 
Gravels,    196. 
Ground-air.    See    Soil,    Atmosphere  of. 

-water.     See  Water,  Ground-. 
Guarana,  146. 

Gymnastic  training,  tables  showing  effects 
of,  on  development,  355,  357. 

Habitations,  construction  of,  192. 
character  of  the  soil,  195. 
chalk,  196. 
clay,  dense  marls,  and  alluvial  soils, 

197. 
clay  slate,  196. 
cultivated  soils,  197. 
granitic,      metamorphic,      and      trap 

rocks,  195. 
gravels,  196. 
limestone   and   magnesium  limestone 

rocks,  196. 
sands,  196. 
sandstones,  196. 
house-drainage,  205. 
water-closets,  206. 
house-drain,  215. 
soil  pipe,  214. 
traps,  212. 

water-supply  for,  211. 
interior  arrangements,  196,  200. 
size  of  rooms,   ventilating  and  heat- 
ing, 200. 
wall-coating,   203. 
lighting,  203. 
materials,    198. 
questions  on,  217. 
site,   194. 
unsanitary,    effects    of,    upon    young 

children,   194. 
water-supply,  205. 
ofBcial    supervision    of   the    sanitary    ar- 
rangements of,  216. 
Hardness  of  water.     See  Water. 
Health    and    life,    relation    of   occupations 
to,    246. 
effect    of    changes    of    temperature    on, 
11,  12. 
prevention  of,  12. 
of    continual    inhalation    of    sewer-a:r 
upon,   27. 
humidity  of  atmosphere  connected   with 

changes  of,  16. 
Influence     of     changes     of     atmospheric 

pressure  on,  7. 
occupations    prejudicial    to,    249. 
Heat,  eflcfts  of  great,   203. 


History    of    epidemic    diseases.      See    Dis- 
eases, Epidemic,  History  of. 
marine  hygiene,  285. 
Hospital,      general,      administration      and 

management  of,   226. 
Hospitals,  construction  of,  219. 

administration  building,  226. 
buildings,  219. 
bathrooms,   224. 
dead-house,  225. 
dining-room,  225. 
disinfecting   chest,    225. 
fireproof   material   in   ceilings,    224. 
floors,  223. 
Johns   Hopkins    Hospital    as   a   model, 

220,  221. 
kitchen,   225. 
laundry,   226. 
pavilion  system,  220. 
questions  on,  228. 
site,  219. 

ventilation  and  heating,  222. 
ward-kitchens,  225. 
water-closets,  224. 
water-supply,  225. 
House,   material   for  building,   198. 
Houses.     See  Habitations. 
Humidity,  absolute,  5. 
low  absolute,  a  cause  of  respiratory  dis- 
eases, 13. 
of  atmosphere  connected  with  changes  of 

health,  16. 

relation  of,  to  atmospheric  pressure,  4. 

to    temperature,    table   showing,    5. 

Hydrants,   out-door,  78. 

Hydrochloric  acid  gas,  poisoning  by,  250. 

Hydrogen,    carburetted,    in    the    air,    27. 

poisoning  by,   252. 
Hydrogen,  sulphuretted,  in  the  air,  27. 

poisoning  by,  253. 
Hydrophobia.     See  Rabies. 
Hygiene,   industrial,  246. 
marine.     See  Marine  Hygiene, 
military    and    camp.      See    Military    and 

Camp  Hygiene, 
personal.     See  Personal  Hygiene, 
prison.    See  Prison  Hygiene, 
school.     See  School  Hygiene. 

Ice,   53. 
contaminated,   54. 
snow,   54. 
Illuminating  gas,  carbon  monoxide  in,  26. 

chronic  poisoning  with,  26. 
Immunity,  theories  of,  379. 
Ehrlich's,    '"2. 
Mctchnikoff's,   381. 
questions    on,    384. 
Impurities   in   water,   63. 

soil,    diseases  spread  by,    116. 
Industrial   hygiene,   246. 


574 


INDEX. 


Industrial  hygiene,  questions  on,  266. 
Infection  by  contaminated  air,  7. 

carriers  of,   387. 
Influenza,    epidemic,    history   of,    428. 

resume   of,    439. 
Ingesta,  disinfection  of,  455. 
Interment.     See   Dead,   Disposal  of. 
Iodine  and  bromine  vapors,  poisoning  by, 
254. 

Kefyr,  143,  144. 
Kerosene,  203. 
Kumys,  143,  144. 

Lactodensimeter,    124. 
Lactometer,  123. 
Lactoscope,  123. 

Lead  pipes  as  conductors   of  water,   dan- 
gers of,  78. 
poisoning,  254. 
Legumes,  134,  135. 
Lentils,  134,  135. 
Lepr  resume  of,  439. 

Life    and    health,    relation   of   occupations 
to,  246. 
expectation   of,    in   abstainers   and   users 
of  alcohol,   table  of,  141. 
Lighting,   203. 

Limestone      and      magnesium      limestone 
rocks,  the,  196. 

Malaria,   resume   of,   439. 

Malarial   fevers   in  soldiers,   280. 

Man,    diseases   of    animals    communicable 

to.     See  Diseases. 
Marine  hygiene,  285. 

bilge,  composition  of,  307. 
tables  of,  308. 

-■water,  of  the  boiler-room,  311. 
of  the  cambuse,  311. 
of  the  engine-room,  311. 
of  the  store-room,  311. 
drainage   of  ships,   297. 
battleships,  297. 
bilge-water,   297. 
tables   of   variation    of   composition 
of    307,  309,   310. 
summary,   301. 
surface   drainage,   300. 
two  methods  of,  297. 
historical,   285. 

morbidity   and   mortality   occurring    in 
seafaring  people,   288. 
casualties     and     disabilities     due     to 
shipwreck,    296. 
tables  of,  296,  297. 
charts  of,  292,  293. 
health  of  the  navy  and  marine  corps 

of    the    United    States,    290. 
tables    of,   290,   291,    294,    295. 


Marine  hygiene,  navy  ration,  325. 

tables  of,  328,  329,  330,  331,  332. 
questions  on,  347. 
ship,  the,  312. 
cleanliness,   318. 
dry  decks,   319. 
table  showing  benefit  of,  319. 
construction,   312. 
battleship,    air-space    of,    table    of, 
318. 
plan  of,   315. 
disinfection,  320. 
carbon  dioxide,  325. 
formaldehyde,  323. 
lime,  324 

mercuric  chloride,  324. 
steam,  323. 
sulphur,   322. 
ventilation,  338. 
different  methods  of,  340. 
systems    of    Idaho    and    Mississippi, 
342. 
tables   of,    345,   346. 
water-supply,  332. 
allowance  of,   per  man,  336. 
analysis   of,    table   showing,    335. 
contamination   of,    336. 
distilled,    table  of,   335. 
distillers,    332. 
scuttle-butt,  337. 
Marriages,  registration  of,  465. 
Mate,  146. 

Measles,    history  of,    425. 
quarantine  of,   558. 
resume  of,  439. 
Meat.      See   Foods   of   Animal    Origin. 
Mechanical  filters.     See  Filters. 
Meningitis,    cerebro-spinal,    epidemic,    his- 
tory of,  429. 
Mercurial   poisoning,   255. 
Methane,   poisoning  by,  252. 
Methods  of  purification  of  sewage,  186.     See 
Sewage,    Methods   of    Purifi- 
cation. 
Micro-organisms  in   sewer-air,   28. 
Military   and    camp   hygiene,   268. 
camp   diseases,    279. 
cholera,  283. 
diarrhea,   279. 
dysentery,  279. 
malarial   fevers,  280. 
phthisis,    283. 
scurvy,    283. 
typhoid  fever,  282. 
typhus  fever,  283. 
venereal  diseases,  283. 
yellow  fever,  282. 
hospital  tents,  276. 
mosquitoes,  281. 
questions  on,  284. 


INDEX. 


575 


Military  and  camp  hygiene,   sanitary  care 
of  camps,  277. 
the  clothing  of  the  soldier,  272. 
the  dwelling  of  the  soldier,  274. 

tents,  276. 
the  food  of  the  soldier,  270. 
table    showing    components    of,    270- 

271. 
table    showing    calories    of    (German 
army),    271. 
the  recruit,  268. 
the  training  of  the  soldier,  269. 
Milk.     See   Foods  of  Animal   Origin. 
Mineral  waters  in  this  country,  classifica- 
tion of,   55. 
table  showing  analyses  of  some  of  the 
more  popular,  60. 
Mines,  fire-damp  in,  27. 
Model   study  room,   232. 
Moore,    J.    M.,    observations    on    relation 
of    respiratory    diseases    to 
low  temperature,  14. 
Morln's  table  for   air-space,   40. 
Mortality   among   residents   of   badly   con- 
structed  dwellings,    192. 
from  typhoid  fever,  table  of,  90. 
from  various  diseases,  table  showing  in- 
fluence of  alcohol  upon,  141. 
table    of    comparative,    before   and    after 

filtration,  88,  89. 
typhoid,  average,  in  cities  supplied  with 
filtered  water,  76. 
in  American  cities,  table  showing,   72- 
75. 
Mosquito,  danger  from,  in  quarantine,  526. 
influence    of,    upon    the   management    of 

yellow  fever,  541. 
transmission  of  disease,   management  of 
epidemics    of    yellow    fever, 
in   the  light   of,    542. 
Mosquitoes  and  camp-life,  281. 
Moulds  in  air,  6. 

spores  of,   In  air,   6. 
Mountain   sickness,   9. 
Mumps,  resume  of,  439. 
Municipal  quarantine.    See  Quarantine. 

National  quarantine.     See  Quarantine. 
Naval   hygiene.      See   Marine   Hygiene. 
Nervous  disorders  in   school-children,   239. 
Nitrates      and     nitrites     in     water.       See 

Water. 
Nitric-acid   fumes   in   factories,   250. 
Nitrogen  in  atmospheric  air,  2. 

Occupation    neuroses,    264. 
Occu(pations    concerned    in    making    dust, 
249. 

hygiene  of.     See  Industrial   Hygiene. 

prejudicial  to  health,  249. 


Occupations,    relation    of,    to    health    and 
life,  246. 
table  showing  average  age  of  certain,  247. 
Odor  of  water,  101. 

significance  of,  101. 
Oleo-margarine.       See    Foods     of    Animal 

Origin,   Butter. 
Organic  matter  in  water.     See  Water. 
Overcrowding  in   cities,   192,    193. 
relation   of,    to    pulmonary    tuberculosis, 
193. 
Oxygen  and  carbon  dioxide  in  ground-air. 

See   Soil,    Atmosphere  of. 
Oxygen  in  atmospheric  air,  2. 
Ozone  in  atmosphere,  6,   30. 
test  for,   30. 

Paraguay  tea,  146. 
Parasites  in  meat,   128. 

cysticercus   cellulosa,    129. 
trichina  spiralis,  128. 
Parkes  and  Kenwood's  table  of  daily  quan- 
tity   of    water    required    by 
human  beings,  47. 
Parkes's  rules  for  ventilation,  41. 
Parotitis,   resume  of,   439. 
Patent    medicines,    amount    of    alcohol    in 

various,  144. 
Peas,  134,  135. 
Pellagra,    134. 
Perflation,  40. 
Person,  disinfection  of,  453. 
Personal  hygiene,  353. 

baths  and  bathing,  357. 
cold,  358. 
taken    when   heated   or   perspiring, 
359. 
cramps,   360. 

drowning,    methods    of    resuscitation 
for,  360. 
Michigan,    361. 
Sylvester's,    360. 
free,   362. 
questions  on,  367. 
rules    for,    359. 
sea-bathing,   358. 

artificial,  recipe  for,  359. 
tepid,  warm,  or  hot,  358. 
clothing,    363. 
absorption    of   gases   and   vapors   by, 

365. 
color,    364. 
dyes,    365. 
fit,    365. 

materials  for,  363. 
animal  skins,  364. 
cotton,    363. 
leather,  364. 


576 


INDEX. 


Personal  hygiene,   clothing,  materials  for, 
linen,   363. 
silk,   364. 
■wool,   363. 
non-inflammable,    process   of   render- 
ing, 365. 
questions    on,    368. 
exercise   and  training,   353. 
amount   required,   356. 
overexertion,     356. 
questions    on,    367. 

tables    showing    effect    of    gymnastic 
training      on     development, 
355,    357. 
questions   on,    367. 
recreation  and  rest,  366. 
Petroleum  vapor,  effects  of,  254. 
Pettenkofer's  method  for  determining  car- 
bon dioxide  in  air,  35. 
Phthisis,   effect  of  rarefied  atmosphere  on, 
10. 
in   soldiers,    283. 
Pioscope,  123. 

Plague,  oriental,  history  of,  391. 
resume  of,  439. 
-vessels.     See  Quarantine. 
Flans  of  intake  and   wattr-tower  in  Wil- 
mington.  Del.,  83. 
of    slow    sand    filters,    85. 
of  storage  reservoir  in  Wilmington,  Del., 
82. 
Pneumonia,  croupous,  fatality  of,  in  users 
of  alcohol,   141. 
resume  of,  439. 
Poisoning  by  absorption  or  local  action  of 
irritating  or  poisonous  sub- 
stances.   See  Poisonous  Sub- 
stances, 
by   inhalation   of   gases   or   vapors.      See 

Gases,   etc. 
chronic,  with  illuminating  gas,  26. 
Poisonous    dust,    diseases    due    to    the    in- 
halation    of     irritating     or, 
258. 
gases    or    vapors,    diseases    due    to    the 
inhalation    of    irritating    or, 
250. 
substances,   diseases  due  to  the  absorp- 
tion or  local  action   of  irri- 
tating   or,    261. 
alkali,   strong.  262. 
arsenic,  261. 

bichromate    of    potassium,    262. 
glass-blowers,    262. 
petroleum,   262. 
phosphorus,  261. 
potassium  bichromate,   262. 
quinine,  262. 


Population,    density   of,    table   on   relation 

of   death-rate   to,   192. 
Porter,   143. 

Principles,   alimentary,    110.      See   Food. 
Proximate,  110.     See  Food. 
Prison   hygiene,    348. 

diseases  most  frequent  in  prisons,   350. 
exercise,    350. 
food,  350. 
punishment,  350. 
questions   on,  352. 
reform,  principles  of,  348. 
site  for,   qualities  necessary,   350. 
Privies  as  sources  of  contamination,  50. 

ventilation    of,    173. 
Privy-vaults,   disinfection   of,   455. 
Ptomaines   in   meat,    129. 
Prophylaxis    against   yellow   fever   on   the 
Texas-Mexican  border,  cam- 
paign of,  543. 
Proteids.     See  Foods. 
Proximate    principles,    110.      See    Food. 
Pulmonary    affections,    chronic,    conditions 
predisposing  to,   25. 
tuberculosis   and   overcrowding,    193. 
Purification  of  water,  storage  and,  77. 
Putrefaction,   bacterium  of,   IfiO. 
definition    of,    369. 
gases  from,    poisoning  by,   253. 

Quarantinable  diseases,   473. 

table  of,  473. 
Quarantine,    472. 
definition    cf,    472. 
diseases,  quarantinable,  473. 

table  of,  473. 
division   of,    two   natural,   473. 
domestic,  488. 
plant  for,  489. 
anchorages,  489. 
barracks,    493. 
bath-house,    493. 
boarding-station,    489. 
boarding-vessel,    489. 
crematory,   494. 

disinfection   by   germicidal   solutions, 
492. 
by    steam-chambers,    490. 
by  sulphur-furnace,   491. 
hospitals,  492. 

steam    disinfecting    chambers,    490. 
sulphur-furnace,    491. 
water-supply,  494. 
wharves,    489. 
regulations,    495. 
disinfectants,    authorized    and    meth- 
ods of   use,   508. 
application  of,  in  quarantine  work, 
512. 


INDEX. 


577 


Quarantine,   domestic  regulations,  applica- 
tion of  disinfectants,  vessel, 
articles    injured    by    steam, 
513. 
bedclothes,  513. 
clothes    and    room    furnishing, 

513. 
cooking     and     eating     utensils, 

514. 
hold  of,   iron,   512. 
holds  of,  513. 
living   apartments,    513. 
textiles,   soiled,    514. 
gaseous,   509. 
formaldehyde  gas,  510. 
sulphur  dioxide,  509. 
physical,  508. 
boiling,  508. 
burning,  508. 
steam,  509. 
solutions,     chemical,    bichloride    of 
mercury,  512. 
carbolic  acid,  512. 
formalin,   512. 
Infection,   495. 

of  State  and  local,  508,  530. 
preamble,   495. 
quarantine,  497. 
requirements,   general,    498. 
special,     Canadian    and    Mexican 
frontiers,   506. 
on  account  of  cholera,  500. 
leprosy,    504. 
plague,    505. 
small-pox,  503. 
typhus    fever,    504. 
yellow  fever,  501. 
relating  to  naval  vessels,  507. 
stations,    maritime,    488. 
flies,    danger  from,  in,  526. 
foreign,   473. 
regulations,    474. 
bills  of  health,  474,  477. 
exemptions,   477. 
form  of,  474-475. 
supplemental,  475,  477. 
form  of,  475-476. 
cargo,  479. 

exemptions,    480. 
efficiency  of,  486. 
inspection  of  vessels,  478. 
passengers  and  crew,  481. 

inspection  card,  form  of,  483. 
ports  exempted  on  Canadian  border, 

477. 
quarantinable  diseases,  474. 
records,  reports,  etc.,  484. 
requirements  at  sea,  484. 
disinfecting   solutions,    486.  | 

37 


Quarantine,    foreign    regulations,    require- 
ments   at    sea,    with    regard 
to  vessels,  478. 
inland,   533. 
camps  of  probation,   536. 
Camp  Perry,  Fla.,  537. 

discipline   of,    5.38. 
detention    camp,    Waynesville,    Ga., 
539. 
cordon,    the    sanitary,    533. 
yellow  fever,   in  Texas,  534. 
interstate,  551. 
notification,    552. 
quarantinable   diseases,   552. 
regulations,  general,  552. 
disinfection,   554. 
for  cholera,  554. 
for  small-pox,  555. 
for  typhus    fever,    556. 
for  yellow  fever,  554. 
yellow  fever,   553. 
mosquito,   danger  from,  in,   526. 
influence  of,   upon  the  management  of 

yellow  fever,  541. 
transmission  of  yellow  fever,   manage- 
ment   of    epidemics    in    the 
light  of,  542. 
municipal,    556. 
diphtheria,    559. 
diagnosis   of,    561. 

directions     for    making    cultures     in 
suspected  cases  of,  561. 
measles,   558. 
scarlet  fever,   559. 
tuberculosis,    562. 
sanatorium  treatment  of,  564. 
plant,   quarantine,   489. 
questions  on,   565. 

railroad,  and  inspection  service,  544. 
medical  inspection  of  immigrants,   550. 
regulations  for  sanitary  inspectors   of, 

548. 
train-inspection     service     during    the 
Brunswick  epidemic,  545. 
school,  242. 

service,  the  national,  527. 
aids    to,    529. 

stations   on    Delaware   Bay   and   River, 
327. 
station,   management  of,  514. 
cholera,  special  measure  against,  521. 
camip,   regulations  for,  524. 
detention,  524. 
hospital,  525. 
inspection,  514. 

vessels,  cholera,  treatment  of,  519. 
plague,  treatment  of,  517. 
yellow  fever,  treatment  of,  515. 
stations,  maritime,  488. 


678 


INDEX. 


Quarantine,     yellow    fever,    campaign     of 

prophylaxis    against,    of   the 

Texas-Mexican    border,    543. 

Influence   of   the   mosquito   upon    the 

management  of,  541. 
management  of  epidemics  of,   in  the 
light  of  the  mosquito  trans- 
mission of,  542. 
Quarantines,    national    inspection    of    all, 
508,    530. 
Instructions  to  officers  making,  530. 
general,  531. 
special,    531. 
Questions  to  Chapter  I,  air,  43. 

to  Chapter  II,  water,  107. 

to  Chapter  III,  food,  156. 

to   Chapter  IV,   the  soil,  170. 

to  Chapter  V,  removal  of  sewage,  190. 

to    Chapter   VI,    construction   of   habita- 
tions,  217.  • 

to  Chapter  VII,  construction  of  hospitals, 
228. 

to  Chapter  VIII,  school  hygiene,  244. 

to  Chapter  IX,  industrial  hygiene,  266. 

to      Chapter      X,      military      and     camp 
hygiene,  284. 

to  Chapter  XI,  marine  hygiene,  347. 

to  Chapter  XII,   prison  hygiene,  352. 

to  Chapter  XIII,  personal  hygiene,  367. 

to   Chapter   XIV,    disposal   of  the   dead, 
373. 

to  Chapter  XV,   the  germ  theory  of  dis- 
ease, 384. 

to  Chapter  XVI,  contagion  and  infection, 
390. 

to    Chapter    XVII,    history    of    epidemic 
diseases,  442. 

to   Chapter  XVIII,    antiseptics,   disinfec- 
tants and  deodorants,   461. 

to  Chapter  XIX,  vital  statistics,  470. 

to  Chapter  XX,  quarantine,  565. 

Rabies,  435. 

resume  of,  439. 
Ragsorters'  disease,  260. 
Rain-water.     See  Water. 
Ration,  navy,  325. 

tables  of,  328,  329,  330,  331,  332. 
Recreation    and    rest.      See    Personal    Hy- 
giene. 
Registration  of  births,  464. 

deaths,  466. 

diseases,   456. 

marriages,  465. 
Regulations,  quarantine.     See  Quarantine. 
Relapsing  fever,  history  of,  419. 

resume  of,  440. 
Removal  of  sewage,  172.    See  Sewage. 
Respiratory    diseases,    relation    of    cold    to 
etiology,  of,  13. 


Respiratory  organs,  certain  diseases  com- 
municable by,  7. 

Restoration  of  apparently  drowned  per- 
sons, 360. 

River-water.     See  Water. 

Roasting,   137. 

Rum,  142. 

Sands,  197. 
Sandstones,  196. 
Sanitary  care  of  camps,  277. 
Scarlet  fever,   history  of,  425. 
quarantine  of,  559. 
resume  of,  440. 
School  hygiene,  229. 

age  to  start  in  school,  235. 
blackboards,  234. 
deskS;  233. 
^  gymnastic  exercises,  235. 
height  of  schools,  230. 
length  of  time  in  school,  235. 
lighting  of  schools,  232. 
model  study  room,  232. 
questions  on,  244. 
ventilation,  229,  230. 
water-closets,  233. 
-life,  diseases  incident  to,  235. 

causes     of    pulmonary    tuberculosis, 

240. 
communicable,  240. 
defective  hearing,  238. 
digestive  derangements,  240. 
disordered  menstruation,  240. 
near-sightedness,  236. 
nervous,  239,  240. 
spinal  curvature,  23S. 
Sea-bath,  artificial,  recipe  for,  359. 
Sedentary  life,   diseases  due  to,  265. 
Septic  tank  method  of  removal  of  sewage, 

186. 
Sewage,    changes    taking    place    in,    table 
of,  185. 
deodorization  of,  173. 
disposal  of,  184. 
methods  of  purification  of,  186. 
bacterial,  186. 
broad  irrigation,  186. 
irrigation    with    copious    underdrain- 

age,  186. 
sedimentation  and  irrigation,  186. 
"septic  tank,"  186. 
sterilization  by  heat,  186. 
more  important  bacteria  found  in,  185. 
purification  of,   a  biological  process,  184. 
removal  of,  172. 
eartn  and  ash-closets,  177. 
-closet,    comparison   of,    with    water- 
closet,  179. 
midden  system,  174. 
questions  to  Chapter  V  on,  190. 
pit  system,  174. 


INDEX. 


579 


Sewage,  removal  of,  pneumatic  system  of 
Liernur,   179. 
privy  and  privy-well  system,  173. 

-well  system,   174. 
reasons  for,  172. 

Rochdale,  or  pail-closet,  system,  175. 
systems  of,  173. 
water-carriage  systems,  180. 
"combined,"   180. 
"separate,"  180,  181. 
total    quantity    of,    for    each    individual, 
172. 
Sewer-air,  27. 
ammonia  in,  27. 
bacteria  in,  27. 
composition  of,  27. 
Sewer-pipe,  170. 
Sheep-pock,  434. 
Ships.     See  Marine  Hygiene. 
Shipwreck,   casualties  and  disabilities  due 
to,  296. 
tables  of,  296,  297. 
Sick-room,  disinfection  of,  454. 
Siguatera,  130. 

Site  for  prisons,  qualities  necessary,  350. 
Small-pox,   history  of,   396.     See  Diseases, 
Epidemic,  History  of. 
quarantine  of,  503. 
resume  of,  440. 
Snow-blindness,  13. 
prevention  of,  13. 
-water,  50. 
Soil,  atmosphere  of,  161. 

contamination  of,   with  sewage,   172. 
in  relation  to  diseases,  162. 
micro-organisms  in,  163. 
movements  of,  163. 
oxygen  and  carbon  dioxide  in,  161. 
significance  of  carbon  dioxide  in,  164. 
character  of,  195. 
physical  and  chemical,  160. 
in   relation   to   construction   of   habita- 
tions, 195. 
conditions    of,    diseases   of   animals    due 

to,  169. 
drainage  of,   170. 
drains,  best  material  for,  170. 
eucalyptus  tree  for,  170,  198. 
sewer-pipe,  170. 
sunflower-plants  for,  170,  198. 
impurities,  diseases  spread  by,  166. 
Questions  to  Chapter  IV  on,  170. 
water  of,  165. 

wet,  diminution  of  disease  due  to,  table 
of,  194. 
drainage  of,   prophylactic  against  pul- 
monary  tuberculosis,  194. 
predisposing    to     pulmonary     tubercu- 

lo.sis,  194. 
fianltary  results  of  drainage  of,  194. 
drains,  drainage-pipe,  170. 


Soldier,  clothing  of,  272. 
dwelling  of,  274. 
food  of,  270. 

infectious  diseases  of,  279. 
yellow  fever,  282. 
typhoid  fever,  282. 
malarial  fever,  280. 
cholera,  283. 
diarrhea,  279. 
phthisis,  283. 
dysentery,  279. 
venereal  diseases,  283. 
training  of,  269. 
Solids,    total,   in   water,    determination  of, 

101. 
Sources  of  drinking-water,  50. 
Solutions,  germicidal,  disinfection  by,  492. 
Spring-water,  54. 

Statistics,  vital.     See  Vital  Statistics. 
Steam  disinfecting  chambers,  490. 
Still-births    among    upper-story    dwellers, 

193. 
Storage  and  purification  of  water,  77. 
reservoir  in  Wilmington,   Del.,  plans  of, 
82. 
Suicide  by  inhaling  fumes  of  charcoal,  26. 

relation  of,  to  seasons,  23. 
Sulphuretted  hydrogen,  in  the  air,  27. 
Sulphur-furnace    491. 
Sulphurous-acid  gas,  poisoning  by,  250. 
Sun's  rays,  dermatitis  from,  12. 
direct  influence  of,  12. 
erythema  from,  12. 
Sun-stroke,  12,  263. 
conditions  predisposing  to,  12. 
prevention  of,  12. 
Sweating  sickness,  history  of,  395. 
Syphilis,  history  of,  430. 
resume   of,   440. 

Table  of  antiseptics,  459. 

of  changes  taking  place  in  sewage,  185, 
186. 

of  comparative  cost  of  digestible  nu- 
trients and  energy  in  dif- 
ferent food  materials  of 
average  prices,  112. 

of  deaths  from  typhoid  fever,  90. 

of  dietary  for  adult  male  of  average 
weight,  HI. 

of  food  adulterations  for  one  year  in 
Illinois,  149. 

of  mineral  waters  in  this  country,  55. 

of  quarantinable  diseases,  473. 

of  standard  dietaries,  Hutchison's,  114- 
115. 

of  the  time-periods  of  contagious  and 
infectious  diseases,  Vach- 
er's,  241. 

showing  analyses  of  artesian  well  water, 
62. 


580 


INDEX. 


Table  showing  analyses  of  bilge-water  in 
warships,   309,  310. 

analyses  of  some  of  the  more  popular 
mineral  waters,    60. 

analyses  of  water-supply  of  warships, 
335. 

average  age-limit  in  certain  occupa- 
tions, 247,  24S. 

benefits  of  dry  deck  cleaning,  319. 

casualties  of  seafaring  people,  296,  297. 

characteristics  of  waters  according  to 
de  Chaumont's  classifica- 
tion, 99. 

comparative  expectation  of  life  iu 
abstainers  and  non-abstain- 
ers, 141. 

comparative  mortality  before  and  after 
filtration,  88,  89. 

comparison  of  carbon  dioxide  and  ni- 
trogen excretion  of  a  man 
at  rest  and  at  work,  118. 

components  of  the  United  States 
Army's  rations,  270-271. 

composition  of  bilge,  308. 

composition  of  kumys,  cows'  milk 
kumys,  and  kefyr,  144. 

composition  of  legumes,  135. 

cubic  air-space  on  warships,   318. 

daily  composition  of  water  in  Ameri- 
can cities,  47-49. 

daily  quantity  of  water  required  by 
human  beings,  47. 

effects  of  gymnastic  training  on  de- 
velopment, 355,  357. 

incubation  period  of  infectious  dis- 
eases, 386. 

influence  of  alcohol  upon  the  mortality 
from  various  diseases,  141. 

morbidity  and  mortality  of  seafaring 
people,  290,  291,  294,  295. 

navy  rations,  328,  329,  330,  331,  332. 

nutritive  ingredients  of  food,  116. 

percentage  of  alcohol  in  patent  medi- 
cines,  144. 

periods  of  quarantine  after  contagious 
diseases,    Whitelegge's,    242. 

proper  proportion  of  air,  40. 

relation  of  atmospheric  pressure  to 
altitude,  3. 

relation  of  death-rate  to  density  of 
population,  192. 

relation  of  humidity  to  temperature,  5. 

relative  number  of  bacteria  found  in 
series  of  wells,  61. 

relative  proportions  of  fat  and  proteids 
in  meat,  127. 

relative  value  of  different  kinds  of 
cheese  in  alimentary  princi- 
ples, 126. 


Table  showing  resistance  of  certain  bac- 
teria to  disinfectants,   448. 
the  sanitary  result  of  drainage  of  wet 

soil,  194. 
typhoid  mortality   in  American   cities, 

72-75. 
uses  of  nutrients  in  the  body,  117. 
variations     in     composition     of    bilge- 
water,  307. 
ventilation  of  warships,  345,  346. 
Tape-worms,  ova  of,  in  water,  63. 
Tea,  146. 

Temperature,   diseases  due  to  exposure  to 
elevated  or  variable,  263. 
effect  of  changes  of,  on  health,  11. 
effect  of,  11,  12. 
effect  of,  prevention  of,  12. 
low,  effects  of,  13. 

relation  of  humidity  to,  table  showing,  5. 
Tents,  hospital,  276. 
Tobacco,  146. 
-amaurosis,  146. 
effects  of,  146. 
Tetanus,  resume  of,  440. 
Trichina  spiralis  in  meat,  128. 
Tuberculosis,  bovine,  435. 
in  soldiers,  282. 

pulmonary,  predisposing  causes  of,  240. 
relation  of  overcrowding  to,  193. 
wet  soil,    drainage   of,   as  a  prophy- 
lactic, 194. 
predisposing  to,  194. 
quarantine  of,  562. 
resume  of,  440. 
sanatorium  treatment  of,  564. 
Tuberculous  meat,  131. 
Turpentine  vapors,  effects  of,  254. 
Typhoid  bacilli  in  ice,  54. 
fever,  epidemics  of,  due  to  contaminated 
water-supply,  66-76. 
epidemics  of,  water-borne,  96,  97. 
history  of,  420. 
in  soldiers,  282. 

mortality    average    in    cities    supplied 
with  filtered  water,  76. 
in  American  cities,  table  showing,  72- 
75. 
table  of  deaths  from,  90. 
Typhus  fever,  resume  of,  440. 

history  of,  421. 
Tyrotoxicon  in  milk,  124. 

Vaccination,  401. 
and  syphilis,  407. 

moae  of  performing  the  operation,  404. 
symptoms,   403. 
Vacher's  table  of  the  time-periods  of  con- 
tagious   and    infectious    dis- 
eases, 241. 


INDEX. 


581 


Vaults,  entombment  in,  371. 
Vegetable  foods,  135. 
Venereal  diseases  in  soldiers,  283. 
Ventilation,   200. 
and  heating,  200. 
artificial,  40. 
definition  of,  38. 
how  accomplished,  40. 
natural,  40. 
of  hospitals,   222. 
of  privies,  173. 
of  schools,  230. 

of  ships,  338.     See  Marine  Hygiene. 
Parkes's  rules  for,  41. 
principles  of,  38. 
proper  system  of,  39. 
questions  on,  45. 
source  of  air  for,  39. 
Ventilators,   200-201. 
Vessels,  cholera.     See  Quarantine, 
plague.     See  Quarantine, 
yellow  fever.     See  Quarantine. 
Violence,     diseases     due     to     exposure     to 

mechanical,  265. 
Vital  statistics,  462. 

death-rate  and  birth-rate,  466. 
questions  on,   470. 
registration  of  births,  464. 
of  deaths,  466. 
of  diseases,  465. 
of  marriages,  465. 

Wall-coating,  203. 
"Water,  46. 
albuminoid  ammonia  in,  95. 
ammonia  in,   from  cattle-manure,  52. 

source  of,  96. 
bacteriological   examination  of,  97,  105. 
media  for,  105. 
procedure,  105. 
bilge-.     See  Marine  Hygiene, 
carbon  dioxide  in,   dangerous  proportion 
of,  78. 
effect  of,  on  lead  pipes,  78. 
excess  of,  effect  of,  on  lead  pipes,  78. 
chemical  analysis  of,  object  of,  94. 

objections  to,  96. 
ohlorides  in,  95. 
classification  of,  de  Chaumont's,  98. 

table  of  characteristics  of,  99. 
clear  but  containing  disease  germs,  96. 
-closets,  206. 

water-supply  for,  211. 
color  of,  63. 
daily  consumption  of,  in  American  cities, 

table  of,  47. 
daily    quantity    of,    required    by    human 

beings,  table  of,  47. 
deep  well,  ammonia  in,  source  of,  96. 

nitrites  in,  source  of,   96. 
drinking-,  62. 


Water-drinking,  bacteria  in,  safe  limit  of, 
98. 
cholera  transmitted  by,  76. 
contamination  of,   by  excrement,  50. 
diseases  due  to  impure,  64. 
cretinism,  64. 
diarrhea,  65. 
dysentery,  65. 
parasitic,  66. 
typhoid,  66. 
limit  of  solid  matter  allOTT-abl?  in,  63. 
sources  of,  50. 
examination  of,  93,  100. 
albuminoid  ammonia,  101. 
chlorine,  103. 

significance  of,  103. 
color,  100. 

significance  of,  100. 
for  lead,  copper,  and  iron,  104. 
free  ammonia,  101. 
hardness,  104. 
nitrates,  102. 

significance  of,  102. 
rtrites,   101. 
odor,  101. 

significance  of  101. 
organic  nitrogen,  101. 
oxygen  consumed,  102. 

significance  of,  103. 
for  phosphates,  105. 
total  solids  in,  101. 
turbidity,  100. 
significance  of,  100. 
filtered,     average    typhoid    mortality    in 

cities  supplied   with,    76. 
freezing,  53. 

from  fresh-water  lakes  and  ponds,  53. 
fungi  and  algee  in,  53. 
ground-,  165. 
contamination  of,  with  sewage,  172. 
influence  of,  on  bacteria  of  decomposi- 
tion, 166. 
on  bacteria  of  putrefaction,   167. 
micro-organisms  in,   166. 
hard    64. 
hardness  of,  63. 
cause  of,  64. 

determination  of,  64,  104. 
permanent.  Pi. 
soap  test  for,  64. 
temporary,  64. 
toial,  64. 
impurities  in,  63. 

mineral,    in    this    country,    classification 
of,  55. 
table  showing  analyses  of  some  of  the 
more  popular,  60. 
nitrates  and  nitrites  in,  95. 

source  of,  96. 
nitrites  and  nitrates  in,  95. 
objectionable  organic  impurities  in,  94. 


582 


INDEX. 


Water,  organic  matter  in,  65. 

nitrogen  in,  95. 
ova  of  tape-worm  in,  63. 
petroleum  in,  63. 
potable,  qualities  of  good,  62. 
proportion  in  tissues  of  animal  body,  46. 
purification  of,  by  alum,  64,  79. 

by  boiling,  78. 

by  bromine,  79. 

by  copper  sulphate,  79. 

by  ferrous  sulphate  and  lime,  64. 

Lind's  method,  78. 

by  ozone,  93. 

by  potassium  permanganate,  79. 
quantity  of,  required  by  human  beings, 

46. 
questions  to  Chapter  II  on,  107. 
rain-,  50. 

qualities  of,  51. 
result   of   decomposition  of   organic   im- 
purities in,  94. 
table  of,  95. 
:.'iver-,  51. 

objections  to,  51. 

self-purification  of,  52. 
salts  in,  95. 
sediment  in,  63. 

examination  of,  63. 
snow-,  50. 
spring-,  54. 
storage  and  purification  of,  77. 

by  sedimentation,  81. 

filtration,   81. 

Impurities  from  containers,  lead  pipes, 
78. 
sulphur  in,  63. 


Water-supply,  494. 
for  hospitals,  225. 
of  ships.     See  Marine  Hygiene, 
transparency  of,  63. 
well,  61. 
artesian,  analyses  of,  62. 

quantity,   62. 
bacteria  in,  61. 
Weather,  influence  on  the  causation  of  dis- 
ease and  mortality,  17. 
Wells,  artesian,  61. 

mineral  contents  of,   62. 
deep,  61. 
Wind,  6. 
dry,  6. 
moist,  6. 
Winds,    mistral,    bora,    northers,    sirocco, 
harmattan,      simoon,      fohn, 
16-17. 
Wine,  142. 

adulteration  of  foreign,  142. 
Wharves,  489. 
Whisky,  142. 

Whitelegge's     table     showing     periods     of 
quarantine   after   contagious 
diseases,  242. 
Whooping  cough,  resume  of,  441. 
Wool-sorters'  disease,  260. 

Yeasts  in  air,  6. 

Yellow  fever,  history  of,  423. 

in  soldiers,  282. 

resume  of,  441. 

vessels.     See  Quarantine. 

Zinc  or  copper  vapors,  poisoning  by,  256. 


RA425 
Rohe 


R63 
1908 


